Dr. Jitendra N. Patel

Dr. Devendra R. Patel

Dr. Mahadev Desai Dr. Shivangi A. Patel Dr. Atul P. Kansara Dr. Jitesh A. Desai Dr. Amit P. Shah Dr. Pravinaben M. Santwani Dr. Mukund M. Prabhakar Dr. Pankaj Modi Dr. Tushar Patel Dr. Niyat Pandya Dr. Haresh Doshi Dr. Manish G. Shah

Dr. Bhavesh Patel Ahmedabad Ahmedabad Zone Dr. Kailashben Parikh Vadodara Vadodara Zpme Dr. Kishor Ruparelia Surat Surat Zone Dr. Vikram Patel Mehsana Central Zone Dr. Bhavesh Devani Morbi West Zone Dr. Rajesh C. Rohit Dadranagar Sourth Zone

9 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 Dear colleagues, Health is a forefront issue of the society. Unhealthy people will surely lead to unhealthy society and a burden to family,society and to the economy. As a doctor it is our prime responsibility to keep society healthy and fit. We should keep our self updated in latest development in the field of medicine. The function of the medical professions does not mean only high technology of the curative medicine; the comparable importance goes to the health education, health promotion, disease prevention and rehabilitation as well as the sustainability of the actions. To reach the ultimate goal of healthy world, medical professions needed to be involved in so many issues such as environment preservation, family life styles, pollution control and so on, which are also the issues amongst the public and policy makers. Therefore, it is our duty to be united and share our information, knowledge, and experience to prevent and find proper solutions to overcome or to suppress the risks of spreading diseases and illnesses. Gujarat medical journal is a platform through which you can share your experience and research to your colleagues. This issue of the Gujarat Medical Journal provides a varity of articles on different subject that will give updated information on all of them. This will be useful to the readers and practitioners in their day to day practice also. We must congratulate the contributors, not only for their study and analysis of the subject, but also for presenting information and findings, in clear and easy language. We urge our IMA members to send your best research article for our journal so that it becomes more informative. “The life so short, the craft so long to learn.”-Hippocrates.

DR. BIPIN M. PATEL DR. JITENDRA N. PATEL

10 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 Dear friends, While putting the second issue of Gujarat Medical Journal in your hands in this year, we regret that, though the issue that was to be published in last July, is being published very late. There was some dispute with the postal department and we had to move the high court of Gujarat and after getting an interim relief from the high court we could start the process of publication. We hope that the next issue of GMJ will be published in February 2014, as per the schedule of its publication. In last five years of time, many new medical collages have started in our state and that will create many new doctors to serve the country and the society. At the same time a demand for new academic minded medical teachers is also increasing. Our hospitals and expertise are world class and that pushes the medical tourism in Gujarat far ahead. Our hospitals and institutes are well equipped with world class equipments and infrastructures. As per the survey carried out by the FICCI and Yes bank, Gujarat is the most favored state for medical treatment in African and European countries. Gujarat is marching to become hub for medical tourism. People from developed and underdeveloped countries come here for treatment and we provide them world best treatment at a cheaper rates then that is available in developed countries. Also we get large number of patients from our own domestic population and this provides ample of opportunities for our colleagues working in hospitals, medical collages and research institutes for research. GMJ provides them a platform. You all know our GMJ is an INDEXED JOURNAL. For last few years, indeed, we get more research articles for publication. Without making any compromise in our laid down standards and policy, it has always remained our effort to make GMJ more informative, more interesting and more popular so that large number of our colleagues read it and utilize the knowledge and information provided in it. For this, we welcome your suggestions and comments also. Our sincere thanks to GSB president Dr. Bipin Patel and hon. secretary Dr. Jitendra N. Patel for encouragement and suggestions. We are grateful to Dr. Kirtibhai Patel and Dr. Mahendrabhai Desai for their guidance and help. Our particular thanks to GMJ ex. editor Dr. Amitbhai Shah for all sorts of help and guidance that he has provided us time to time. Promising you the best reading, With regards,

11 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 2013-2014

DR. BIPIN M. PATEL AHMEDABAD MOB. 98250 62381 DR. PRAGNESH C. JOSHI SURAT MOB. 98241 87892 DR. VINAY A. PATEL DR. JAYESH M. VAGHASIA DR. BHUPENDRA M. SHAH DR. CHETAN N. PATEL DR. NAVIN D. PATEL DR. BHASKAR MAHAJAN DR. JITENDRA N. PATEL AHMEDABAD MOB. 98253 25200

DR. DEVENDRA R. PATEL DR. SHAILESH S. SHAH ANAND DR. BHARAT R. PATEL DR. M. A. SANTWANI DR. PRADIP BHAVSAR DR. PARESH GOLWALA DR. VINOD NOTICEWALA DR. RAJIV D. VYAS

DR. DILIP C. VAIDYA

12 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 I.M.A. G.S.B. NEWS BULLETIN (Gujarat Medical Journal)

Vol. : 68 DECEMBER-2013 Issue : 2 CONTENTS

* State President and Hon. Secretary's Message ...... 10 * From the Desk of Editors...... 11 REVIEW ARTICLE

* Role of PET scan in Clinical Practice ...... 19 Patel Apurva A*, Patel Bipin M**, Patel Kirti M***

* Pregnancy And General Surgery ...... 23 Dr. Babu S. Patel*

ORIGINAL ARTICLE

* Comparison of Misoprostol and Dinoprostone for elective induction of labor in nulliparous women at full term pregnancy...... 26 Masum B Leuva*, Surbhi Gupta*, Nilesh A Shah**

* Awareness of Ergonomic Guidelines regarding laparoscopic surgeries, its Practice among Surgeons and Comfort level during and after surgery...... 31 Dr. Yogendra S. Modi*, Dr. Manoranjan R. Kuswaha**, Dr. Sumit Pukhraj Dave***

* Sero prevalence of HBV, HCV, HIV and syphilis among blood donors at a tertiary Care Teaching Hospital in Western India...... 35 Dr. Nirali Shah*, Dr. J.M.Shah**, Dr. Preeti Jhaveri***, Dr. Kazoomi Patel****, Dr. C.K.Shah*****, Dr. N.R.Shah******

* Increasing trend of HCV reactivity in healthy blood donors and multitransfused thalassemia patients of Gujarat State ...... 40 Dr. Sangita D. Shah*, Dr. M. D. Gajjar**, Dr.Nidhi M. Bhatnagar***

* Screening for Postpartum Depression...... 46 Dr. Ashish V Gokhale*, Dr. Amit Vaja**

* Analysis of 63 patients of MDR TB on DOTS plus regimen : An LG hospital, TB Unit, Ahmedabad experience. ...52 Dr. Kapadia Vishakha K.*, Dr. Tripathi Sanjay B.**

* Trends of Suicidal Poisoning Deaths in Females of Ahmedabad (Gujarat Region) ...... 58 Dr. Prajapati KB*, Dr. Satani Dipali**, Dr. Prajapati TB*, Dr. Merchant SP***

* Role of Cervical Encirclage in Prevention of Preterm Delivery ...... 64 Dr. Ami V. Mehta*, Dr. Harshad M. Ladola**, Dr. Bina M. Raval***, Dr. Kartik Morjaria****, Dr. Khushali Gandhi*****, Dr. Swati Thakker*****

* Unstable Intertrochanteric Fractures In High Risk Elderly Patients Treated With Primary Bipolar Hemiarthroplasty: Retrospective Case Series ...... 68 Dr. Nikunj Maru*, Dr. Kishor Sayani**

* Role of ultrasonography in evaluation of orbital lesions...... 73 Dr. Hemang D. Chaudhari*, Dr. Gurudatt N. Thakkar***, Dr. Viplav S. Gandhi**, Dr. Parth J. Darji*, Dr. Hiral K. Banker*, Dr. Hemadri Rajwadi

GMJ 13 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 I.M.A. G.S.B. NEWS BULLETIN (Gujarat Medical Journal)

Vol. : 68 DECEMBER-2013 Issue : 2

* A Study of Prevalence of Hypertension in School Children ...... 79 Dr. Banker Chirag A*, Dr Jitesh Chavda**, Dr Khyati M. Kakkad***, Dr Panchsilla Damor****

* Study of Incidence of Helicobacter Organisms in Cases of Gastritis...... 91 Dr. Moxda S. Patel*, Dr. Alpa A. Shah**, Dr. Himanshu P. Patel***, Dr. Deepak S. Joshi ****

* Study of Incidence of Congenital Anomalies In New Borns ...... 97 Dr. Kanan Shah*** , Dr. C.A.Pensi

RESEARCH ARTICLE

* Study of Feto-Maternal outcome of Teenage Pregnancy at Tertiary Care Hospital ...... 100 Dr Rajal V Thaker*, Dr Mian V Panchal**, Dr Rupa C Vyas***, Dr Sapana R Shah*, Dr Parul T Shah****, Dr Kruti J Deliwala***

CASE REPORT

* Anesthetic management for emergency caesarean hysterectomy in a patient with placenta accreta...... 104 Smita R. Engineer*, Chirag Patel**, Mrunalini Patel**, B. J. Shah***

* Peutz-Jeghers syndrome...... 106 Swati B. Parikh*, Biren J. Parikh**, Hitesh A. Prajapati***, C.K. Shah**** , N.R. Shah ****

* Rupture of uterus at 14 weeks pregnancy with adherent placenta- a rare case reportancy '' in a rural based tertiary care hospital” ...... 109 Nipa Modi*, S.B Vaishnav**, Nitin S. Raithatha*

* A Case of Severe Carbon Monoxide Poisoning Due to Gas Geyser with Cerebeller Involvement...... 111 Dr Heli S Shah*, Dr. Shailesh H Darji**, Dr Krunal Padhiyar***, Dr Amit P Bhatt****, Dr Sudhir V shah*****

* Goodpasture's Syndrome with Immune Thrombocytopenia: An unusual “Autoimmune Mosaic”...... 113 Dr. Tripathi Sanjay B.*, Dr. Kapadia Vishakha K.**, Dr. Jethawa Ashish R.***

* Giant Gluteal Pleomorphic Liposarcoma – A rarity...... 115 Dr. Vikas Bathla*, Dr. Pukur Thekdi**, Dr. Yogendra D. Shah***, Dr. Mukesh Kothari****, Dr. Archit Patel*****, Dr. Parth Nathwani*****

* Midgut malrotation with incidental nutcracker syndrome in adulthood : case report and literature review ...... 118 Dr. Harish N. Raheja*, Dr. Hasmukh B. Vora**, Dr. Mahendra S. Bhavsar***

* A Case Series of Gestational Trophoblastic Tumor - Benign Mole To Life Threatening Perforating Mole...... 121 C. S. Vyas*, M.P. Patel*, Amar Kukhi**, S.B. Vaishnav***

* Congenital Intra-hepatic Porto-systemic Venous Shunt in an adult male...... 124 Dr. Megha Sanghvi*, Dr. Yashpal Rana**, Dr. Hemant Patel***

* Mandatory Submission Form...... 127

* Instruction of Authors...... 128

GMJ 14 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 REVIEW ARTICLE Role of PET scan in Clinical Practice Patel Apurva A*, Patel Bipin M**, Patel Kirti M*** Associate Professor*, Professor and Head**, Dean*** Department of Medical and Pediatric Oncology*, Department of Anesthesiology**, The Gujarat Cancer and Research Institute***, Gujarat Cancer Society*** KEY WORDS : PET scan, FDG, metastases

ABSTRACT PET scan is an emerging image modality in clinical practice and especially useful for cancer cases. The principal clinical applications, benefits and shortcomings of this imaging technique are reviewed here.

INTRODUCTION Non oncological applications : Noninvasive imaging is of fundamental and increasing Neurological applications importance in the daily management of the patient in Presurgical assessment of medically refractory complex clinical practice. This especially holds true in cancer partial seizures where MR is normal, equivocal or patients as morbidity is more in such patients and conflicts with EEG localization objective imaging tests are required to be used at different times during the course of the disease to monitor disease Evaluation of memory loss/neurological signs suggestive staging, prognosis, efficacy (or lack of efficacy) of of dementia and differentiation of types of dementia in treatment. PET scan is a newer modality of imaging with selected patients. increasingly newer applications more so in cancer Cardiological indications : patients. · Assessment of myocardial viability in patients with Principles of operation ischemic heart failure and poor left ventricular Positron emission tomography (PET) is a nuclear medical function being considered for revascularization, imaging technique that produces a three-dimensional usually in combination with perfusion imaging with image or picture of functional processes in the body.1 The sestamibi/tetrofosmin or ammonia/rubidium. system detects pairs of gamma rays emitted indirectly by Infection imaging : a positron-emitting radionuclide (tracer), which is · Detection of site of focal infection in immune introduced into the body on a biologically active molecule. compromised patients or problematic cases of Three-dimensional images of tracer concentration within infection the body are then constructed by computer analysis. In modern scanners, three dimensional imaging is often · Evaluation of vascular graft infection in selected accomplished with the aid of a CT scan performed on the cases patient during the same session, in the same machine. Pyrexia of unknown origin (PUO) : If radiotracer chosen for PET is FDG, an analogue of · To identify the cause of a PUO where conventional glucose, the concentrations of tracer imaged will indicate investigations have not revealed a source. tissue metabolic activity by virtue of the regional glucose Oncology applications : uptake.2 Using this tracer to explore the possibility of cancer metastasis (i.e., spreading to other sites) is the Brain most common type of PET scan in standard medical care · To differentiate between tumor recurrence and (90%). Now, many other radiotracers are used in PET to radiation necrosis in patients treated previously image the tissue concentration of many other types of with cranial irradiation. molecules of interest. · Identifying the grade of malignancy where there is ClinicalApplications uncertainty on anatomical imaging and functional 3 PET is both a medical and research tool. Main clinical assessment would assist biopsy. fields of PET scan are oncology, cardiology, and neurology. Correspondence Address : Dr. Apurva A. Patel Medical OPD No.80, GCRI, New Civil hospital campus, Asarwa, Ahmedabad 380016 Email id : [email protected]

GMJ 19 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 · Assessment of suspected high grade · Especially in the case of failed biopsy, a technically transformation in low grade glioma. difficult biopsy or where there is a significant risk of · Differentiation of cerebral tumor from atypical a pneumothorax in patients with medical co infection in immunocompromised patients with morbidities indeterminate lesions on MR/CT. · Assessment of suspected disease recurrence Head and neck tumors · To differentiate between treatment effects and · Staging of patients where staging is difficult recurrent cancer clinically or where there is uncertainty on other · Staging of patients with small cell lung cancer with imaging or equivocal findings that would preclude limited disease on CT being considered for radical radical treatment therapy. · Staging or restaging of patients with a high risk of · Pleural malignancy disseminated disease such as advanced loco regional disease and primary sites with a high · To guide biopsy in patients with suspected pleural propensity for disseminated disease such as malignancy nasopharyngeal cancer.4 · To exclude extra-thoracic disease in proven · To identify the primary site in patients presenting mesothelioma in patients considered for with metastatic carcinoma in cervical lymph nodes, multimodality treatment including radical with no primary site identified on other imaging. surgery/decortication. · Response assessment 3-6 months post Breast carcinoma chemoradiotherapy in patients with residual · Assessment of multi focal disease or suspected masses following treatment. recurrence in breast cancer.7 · To differentiate between radiation induced · edematous changes versus active tumor tissue. Differentiation of treatment induced brachial plexopathy from tumour infiltration in symptomatic · To rule out metastatic disease in locally advanced patients with an equivocal or normal MR. cancer before major operative procedure. · Assessment of extent of disease in selected Lymphoma patients with disseminated breast cancer before · Staging of patients with Hodgkin's disease (HD) therapy. and Non Hodgkin's lymphoma (NHL) and as baseline for comparison with treatment response · Assessment of response to chemotherapy in scan.5 patients whose disease is not well demonstrated using other techniques; for example, bone · Interim and end of treatment response assessment metastases of patients with HD and aggressive NHL. · Evaluation of suspected relapse for FDG avid Hepatopancreaticobiliary cancers lymphomas in symptomatic patient. · Staging of potentially operable primary · Staging of suspected post transplant hepatobiliary or pancreatic malignancy lymphoproliferative disorder (PTLD). (cholangiocarcinoma, gallbladder carcinoma or · Prior to bone marrow transplant to assess volume hepatocellular carcinoma) where cross sectional of disease and suitability for transplant imaging is equivocal for metastatic disease,who · are fit for resection and a positive PET-CT would To determine extent and identify a suitable biopsy 8 site in patients with low grade lymphomas in whom lead to a decision not to operate. there is suspected high grade transformation. · Suspected recurrence of hepato-pancreatico- Lung carcinoma biliary cancer in selected patients, where other imaging is equivocal or negative. · Staging of patients considered for radical treatment of non-small cell lung cancer especially Colorectal carcinoma mediastinal nodes <1 cm on CT or mediastinal · Staging of patients with synchronous metastases nodes between 1–2 cm on CT or equivocal lesions at presentation suitable for resection or patients that might represent metastases such as adrenal 6 with equivocal findings on other imaging; for enlargement. example, pulmonary or liver lesions.9 · Characterization of a solitary pulmonary nodule

20 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 · Restaging of patients with recurrence being Myeloma considered for radical treatment and/or · Assessment of patients with apparently solitary metastatectomy plasmacytoma or patients with ambiguous lytic 12 · Detection of recurrence in patients with rising lesions on skeletal survey. tumour markers and/or clinical suspicion of · Suspected relapse in patients with non-secretory recurrence myeloma or predominantly extramedullary · Evaluation of indeterminate presacral masses post disease. treatment. Skin tumours Thymic carcinoma · Staging and assessment for distant disease in patients with melanoma when radical dissection is · Staging of patients considered for surgical contemplated (nodal or metastatic disease). resection · To exclude primary malignancy where · Assessment of indeterminate thymic lesions if dermatomyositis is suspected to represent being considered for radical treatment paraneoplastic manifestation. Oesophagogastric carcinoma Musculoskeletal tumours · Staging/restaging of patients with oesophageal or · Assessment of suspected malignant oesophago gastric carcinoma, suitable for radical transformation within plexiform neurofibromas in treatment, including patients who have received patients with neurofibromatosis type 1 neo adjuvant treatment.10 · Staging of high grade sarcomas, unless already · Evaluation of suspected recurrence of proven to have metastatic disease, especially oesophagastric tumours when other imaging is Ewing's sarcoma, rhabdomyosarcoma, negative or equivocal leiomyosarcoma, osteosarcoma, malignant fibrous Gastrointestinal stromal tumours histiocytoma, synovial sarcoma and myxoid liposarcoma.13 · Staging prior to treatment in patients who are likely · to require systemic therapy Preamputation in the setting of a high grade sarcoma where the detection of distant disease will · Response assessment to systemic therapy alter the surgical management Kidney and ureter · To stage patients with metastatic sarcoma · Assessment of metastatic renal and ureteric considered for liver or lung metastatectomy where carcinoma in difficult management situations or anatomical imaging has not identified any extra when standard imaging is inconclusive thoracic or extra hepatic disease which would preclude surgery · Assessment of renal carcinoma at staging in · selected cases with equivocal findings on other Response assessment in high grade sarcomas imaging (recognizing that ~50% of renal cell Paraneoplastic syndromes carcinoma may not be FDG avid and that the tracer · To detect an occult primary tumour in selected is excreted into the urinary tract) patients with non metastatic manifestations of Gynaecological malignancy neoplastic disease when other imaging is negative or equivocal · Staging or restaging of patients with uterine carcinoma (cervix/endometrium)considered for Carcinoma of unknown primary exenterative surgery · Detection of the primary site when imaging and · Staging of patients with cervical cancer suspected histopathology has failed to show a primary site, of having locally advanced disease with suspicious where the site of tumor will influence choice of findings such as abnormal pelvic nodes on MR or at chemotherapy. high risk of paraaortic nodal or distant metastatic Neuroendocrine tumours 11 disease. · Staging or restaging of selected patients with · Suspected recurrence of endometrial and/or poorly differentiated neuroendocrine tumours prior cervical carcinoma when other imaging is to treatment with negative or normal inconclusive. metaiodobenzylguanidine (MIBG) and octreotide scans.14

21 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 · Assessment of possible multifocal disease in CONCLUSION patients with paraganglioma considered for PET scan with its widespread applications has emerged surgery as an indispensable tool in the detection, staging, · Staging and response assessment of treatment monitoring, and identification of recurrent osteosarcoma and Ewing's sarcoma in patients disease in a large number of malignancies. with negative bone scintigraphy REFERENCES PET CT may be helpful in paediatric or adolescent 1. Phelps M. Positron emission tomography provides molecular patients with Wilms' tumours,MIBG negative imaging of biological processes. Proc Natl Acad Sci U S A 2000;97:9226. neuroblastoma, Hepatoblastoma, Langerhans' cell 2. Do, T., C-N. Wan, V. Casella, J.S. Fowler, A.P. Wolf, M. Reivech, histiocytosis. and D.E. Kuhl, ``Labeled 2-deoxy-D-glucose analogs. -labeled 2-deoxy-2-fluoro-D-glucose, 2-deoxy-2-fluoro-D-mannose and Benefits and shortcomings C-14-2-deoxy-2-fluoro-D-glucose, The Journal of Labelled MRI and FDG-PET scan imaging serve to identify primary Compounds and Radiopharmaceuticals 1978; 14:175-182.Vignati F, Loli P. Additive effect of ketoconazole and octreotide in the or metastatic or paraneoplastic disease and monitor treatment of severe adrenocorticotropin-dependent response to therapy. hypercortisolism. J Clin Endocrinol Metab 1996;81:2885. For most malignancies, FDG-PET will be helpful in the 3. Chen W. Clinical applications of PET in brain tumors J Nucl Med 2007;48:1468–1481. setting of suspected or proven recurrence. Its utility in the 4. Kim SY, Roh JL, Yeo NK et al.Combined 18F-fluorodeoxyglucose- primary setting depends on the availability and positron emission tomography and computed tomography as a information derived from structural imaging studies. primary screening method for detecting second primary cancers and distant metastases in patients with head and neck cancer.Ann Some primary malignancies show relatively low uptake of Oncol 2007;18:1698–1703. FDG, which reflects their low glucose metabolism, lower 5. Juweid ME, Stroobants S, Hoekstra OS et al. Use of positron expression of glucose transporters, a high rate of FDG emission tomography for response assessment of lymphoma: dephosphorylation (e.g., hepatocellular carcinoma), and consensus of the Imaging Sub-Committee of International Harmonization Project in Lymphoma.J Clin the histologic composition of the lesion. Oncol2007;25:571–578. Most well-differentiated malignant tumors, including 6. Shon IH, O'Doherty MJ, Maisey MN.Positron emission differentiated, iodine-avid thyroid cancer, many primary tomography in lung cancer.Semin Nucl Med 2002;32(4):240–271. prostate and renal cancers, also show low FDG uptake.15 7. Rosen EL, Eubank WB, Mankoff DA. FDG PET, PET/CT and breast cancer imaging. Radiographics 2007; 27:S215–S229 Indolent lymphomas also show relatively low FDG 8. Garcea G, Ling Ong S, Maddern GJ. The current role of PET-CT in uptake. As these malignancies become more aggressive the characterization of hepatobiliary malignancies. HPB 2009; and clinical disease progresses, they will become 11:4–17. detectable on FDG PET, and it can then help in monitoring 9. Brush J, Boyd K, Chappell F et al. The value of FDG PET/CT in the response to chemotherapy or experimental therapies pre-operative staging of colorectal carcinoma: a systematic review and economic evaluation. Health Technology Assessment (e.g., in castration-resistant metastatic prostate cancer) 2011;15(35). and also provide prognostic information. 10. Flanagan FL, Dehdashti F, Siegel BA et al. Staging of esophageal As the normal brain metabolizes glucose almost cancer with 18F fluorodeoxyglucose positron emission tomography.AJRAm J Roentgenol1997;168:417–424. exclusively as a fuel, FDG uptake will be high. Thus, 11. Grigsby PW. Role of PET in gynecologic malignancy. Curr Opin tumors with glucose metabolism lower than or even equal Oncol 2009; 21(5):420–424. to that in normal cortex (e.g., low-grade astrocytomas) 12. Sager S, Ergül N, Ciftci H, Cetin G, Güner SI, Cermik TF.The value may not be detected on FDG PET. of FDG PET/CT in the initial staging and bone marrow involvement of patients with multiple myeloma. Skeletal Radiol 2011; 40(7): False-positive findings may occur due to increased 843–847. glucose metabolism and FDG uptake within brown 13. Nanni C, Marzola MC, Rubello D, Fanti S. 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22 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 REVIEW ARTICLE Pregnancy And General Surgery Dr. Babu S. Patel* *M.D., Professor Of Obstetrics And Gynecology Smt. N H L Municipal Medical College, Sheth V S General and Sheth C M Hospital, Ellisbridge, Ahmedabad 380006 KEY WORDS : Spinal anesthesia, Intrathecal Clonidine, Postoperative analgesia About 0.75- 2% of pregnant women undergo non obstetric pregnant patients undergoing cholecystectomy6 . These surgery during their pregnancy. Changes in maternal- patients may be managed with ERCP (Endoscopic fetal physiology, the enlarging gestation, and changes in Retrograde Cholangio Pancreato-graphy) and ES maternal organ placement can make diagnosis and (Endoscopic Surgery) in all three trimesters with no treatment challenging1 . increase in fetal morbidity or mortality or congenital abnormalities7 . Pancreatitis during pregnancy is rare, Although the decision to operate may at times seem 8 complicated, it can be simplified. According to Dr. J. M. T. occurring in 0.05% of all pregnancies . Gallstones 2 account for over 90% of pancreatitis seen in the pregnant Finney, there are only three valid reasons to operate : patient. 1. Tosave life (haemorrhage, peritonitis) Urolithiasis is commonly encountered during pregnancy. 2. Torelieve suffering ( cholelithiasis, cancers) The risk during pregnancy ranges from 0.03% to 0.53%9 . 3. To correct significant anatomical deformities Pregnancy results in numerous normal anatomic and (Intestinal obstruction, stones) physiologic changes that may increase the risk for renal The most common non obstetrical surgical emergencies stone formation. When conservative therapy fails patient complicating pregnancy are acute appendicitis, should be considered for the appropriate line of cholecystitis, intestinal obstruction, incision and drainage management depending on the site of stone. In modern of pus, dental problems, vehicular and other injuries and surgical approach if the stone is proximal, the preferred burns. Other conditions that may require surgery during way is diversionary procedure- ureteral stent placement pregnancy include ovarian cysts, masses or torsion, and percutaneous nephrostomy. Ureteroscopy has symptomatic cholelithiasis, adrenal tumors, splenic become popular treatment modality for distal stone. disorders, etc. Diagnostic Imaging Acute appendicitis occurs with the same frequency in In certain situations, diagnostic radiology is an gravid and non gravid females of the same age and is the unavoidable part of evaluation of the pregnant surgical most common cause of acute surgical abdomen during patient and the benefits should be weighed against an pregnancy, leading to appendectomy in 1 out of every accurate assessment of risk. Although there is a concern 2000 pregnancies.Diagnostic delay and subsequent appendiceal perforation is the cause of preterm labor and about teratogenicity of exposure from 5-10 rad, serious 10 fetal loss in as many as 35% of cases3, 4 . When risk to the fetus is known to occur only above 10 rad . appendicitis is suspected, the decision to operate should ACOG has issued the following guidelines concerning the be based on clinical grounds, just as in the non pregnant use of an X-ray examination or exposure during patient. pregnancy. Symptomatic cholelithiasis is the second most common Ø Exposure to less than 5 rads has not been non gynecological condition requiring surgery during associated with an increase in fetal anomalies or pregnancy. Many studies have shown that multiparty and pregnancy loss. abnormal gallbladder motility during pregnancy increase the risk of developing gallstones. The management of Ø Concern about possible effects of ionizing cholelithiasis is controversial in terms of surgery versus radiation exposure should not prevent medically medical. Those with obstructive jaundice, acute indicated diagnostic X-ray procedures from being cholecystitis failing medical management, gallstone performed on a pregnant woman. pancreatitis, or suspected peritonitis should be treated Ø 5 During pregnancy, other imaging procedures not surgically . associated with ionizing radiation should be Choledocholithiasis accounts for only 5% of jaundice considered instead of X-rays when appropriate. during pregnancy and is seen in less than 10% of all

Correspondence Address : Dr. Babu S. Patel, MD 7-B, Amulakh Society, Kashiba Road, Ranip, Ahmedabad 382480, India E-mail: [email protected]

GMJ 23 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 Maternal and Fetal Risks Ø A multidisciplinary plan is necessary in the event of The safe time to operate on the pregnant patient is during persistent fetal distress, e.g., performing an the second trimester, when the risks of teratogenesis, emergency caesarean delivery. miscarriage, and the preterm delivery are lowest11 . The Ø Tocolytics should not be used prophylactically, but abortion rate is highest in the first trimester (12%). During when signs of preterm labor are present in the second trimester, there is about 5% to 8% rate of coordination with obstetric consultation. preterm delivery, which increases to 30% of all pregnant Laparoscopy in Pregnancy patients undergoing non gynecological surgery in the Laparoscopic procedures such as diagnostic third trimester. Finally the gravid uterus in the second laparoscopy, adnexal surgery, appendicectomy, trimester is not yet large enough to obscure the operative splenectomy, cholecystectomy and management of field, as occurs in the third trimester. Pregnancy itself ectopic and heterotrophic pregnancies are relatively safe does not increase the risk of surgical maternal mortality, and effective during pregnancy, if certain precautions are rather morbidity and mortality are increased when the taken. correct diagnosis is missed, when surgery is delayed, or Pneumoperitoneum during Pregnancy when postoperative complications occur. This can In pregnant patient the pneumoperitoneum increases the increase the maternal mortality rate to as high as 15% and intra-abdominal pressure and this causes decreased the fetal loss rate up to 60%, which is usually caused by inferior venacaval return to the heart, hence decreased maternal hypoxia and hypotension. cardiac output. This also leads to decreased uterine blood Fetal Considerations flow in turn cause fetal hypoxia and fetal death. Fetus is a hidden patient in the womb of the pregnant Pneumoperitoneum decreases the diaphragmatic female and its health should be considered by surgeon movement and causes increase in peak airway pressure, and anesthetist both. Some points should be kept in decrease in functional reserve capacity, increased mind11 : ventilation perfusion mismatch, decreased thoracic compliance and increased pleural pressure. CO2 used Ø Maintain uteroplacental blood flow and oxygenation. during pregnancy gets absorbed across the peritoneum Decreased uteroplacental blood flow may be due to and leads to respiratory acidosis in patient and her fetus12 . maternal hypotension or increase in uterine artery resistance. Precautions for safe Laparoscopic Surgery during Pregnancy2 Ø Avoid teratogenic drugs during anesthesia. Diazepam and nitrous oxide are considered safe during Ø Surgery should be done in second trimester. In third pregnancy as no teratogenicity has been detected. trimester, surgery should be postponed if possible until after delivery. Ø Avoid preterm labor. Manipulation of uterus should be minimum possible. Ø Nasogastric incubation is a must in all cases to prevent aspiration into lungs. Fetal Monitoring during Surgery Ø Dorsal lithotomy position in first half of pregnancy is Ø Intermittent or continuous fetal heart monitoring safe, but in second half, to prevent inferior venacaval should be considered. compression, lateral recumbent position is ideal. Ø Tran abdominal monitoring may not be possible Ø Hypotension should be avoided and proper fluid during abdominal procedures or when the mother is replacement should be done. very obese. A vaginal probe may be considered in selected cases. Ø Ideal method of commencing pneumoperitoneum is open Hasson trocar method. Ø Loss of beat to beat variability and decreased baseline FHR are common after administration of anesthetic Ø Tocolysis is indicated if signs of uterine irritability are agents but decelerations suggest fetal hypoxemia. present. Ø An unexplained change in FHR mandates evaluation Ø Decrease operation time by using adequate number of maternal position, blood pressure, oxygenation, of ports and most experienced surgeon. acid-base status, and inspection of the surgical site to Ø Maternal hyperventilation to maintain end-tidal CO2 ensure that neither surgeons nor retractors are pressure at 32 mmHg. impairing uterine perfusion. Monitor maternal Ø Lower CO2 insufflation pressure of less than 12 temperature perioperatively. mmHg to avoid fetal acidosis.

24 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 Ø Electrocautery should be used with care and the REFERENCES smokes containing carbon monoxide should be 1. Dr. Pradeep Garg, Dr. Divya Awasthi. General Surgery in evacuated promptly to avoid fetal acidosis. Pregnancy. Indian Obstetrics and gynecology. 2011;1:24-27. Ø Entry of all instruments should be under direct vision 2. John A. Rock, Howard W. Jones III, Te Linde's operative to avoid injury to uterus. Gynecology, tenth edition, 2010. Ø 3. Babaknia A, Parsa H.Appendicitis during pregnancy. Obstet All specimens should be removed with endobag to Gynecol. 1977; 50(1):40-44. avoid spillage. 4. Sharp HT. The acute abdomen during pregnancy. Clin Obstet Ø Manipulators should never be fixed to cervix or Gynecol. 2002;45(2):405-13. vagina. 5. McKellar DP, Anderson CT, Boynton CI. Cholecystectomy during pregnancy without fetal loss. Surg Gynecol Obstet. Postoperative Care 1992;174(6):465-8. The FHR and uterine activity should be monitored during 6. Simon JA. Billiary tract disease and related surgical disorders recovery from anesthesia. Adequate analgesia should be during pregnancy. Cli Obstet Gynecol. 1983;26:810-21. obtained with systemic or spinal opioids. Regional 7. Ballie J, Cairns SR, Putnam WS et al. Endoscopic management of choledocolithiasis during pregnancy. Surg Gynecol Obstet. 1990; anesthesia may be preferable because systemic opioids 171:1-4. may reduce FHR variability. The routine and prolonged 8. Block P, Kelly TR. Management of gallstone pancreatitis during use of non steroidal anti-inflammatory drugs is avoided pregnancy and postpartum period.Surg Gynecol Obstet. 1989; because of potential fetal effects (e.g. premature closure 168: 426-28. of ductus arteriosus and development of 9. Swanson SK, Heilman RL, Eversman WG. Urinary tract stones in oligohydramnios). Early mobilization and venous pregnancy, Surg Clin NAm. 1995;75:123-42. thrombosis prophylaxis should be considered as patients 10. Schwartz HM, Reichling BA. Hazards of radiation exposure for are at risk of thromboembolism. pregnant women. JAMA. 1978;239:1908. 11. Mazze RI, Kallen B. Reproductive outcome after anaesthesia and Counselling and Reassurance operation during pregnancy. Am J Obstet Gynecol. 1989;161:1178- A pregnant patient requiring surgery will naturally be 85. extremely nervous and anxious. The patient should be 12. Steinbrook RA, Brook DC, Dutta S. Laparoscopic cholecystectomy during pregnancy. Surg Endosc. 1996;10(5):511-15. reassured about the safety of anesthesia but should also be warned about the increased risk of first trimester abortions and premature delivery. It is important to document details of the risk discussed in the patient's records.

25 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 Comparison of Misoprostol and Dinoprostone for elective induction of labor in nulliparous women at full term pregnancy. Masum B Leuva*, Surbhi Gupta*, Nilesh A Shah** * Resident, **Professor & Head of unit Obstetrics & Gynecology, B.J.Medical College, Ahmedabad KEY WORDS : Misoprostol, dinoprostone, Induction of labor.

ABSTRACT : Background Success of labor induction depends largely on the favorability of the cervix at the onset of induction. When the cervix is unfavorable, induction attempts may fail, resulting in prolonged labor and caesarean delivery. These lengthen hospitalization and increase medical cost. In the 1960s, successful induction was observed in 96% of women having favorable cervices but only in 63% of those having unfavorable cervices Objective The objective of this randomized prospective study was to compare the efficacy of vaginal misoprostol 25 mcg every four hours and 0.5 mg dinoprostone, administered every eight hours for a maximum of three doses, for elective induction of labor in a specific cohort of nulliparous women with an unfavorable cervix and more than 40 weeks of gestation. Material and Methods One hundred pregnant women with more than 285 days of gestation were recruited and analyzed. Primary outcome was number of women who achieved favorable Bishop Score >5 or active labor by day 2. Secondary outcomes were time interval from insertion to delivery, cardiotocographic abnormalities, delivery and neonatal outcome Results The induction-delivery interval was significantly lower in the misoprostol group than in the dinoprostone group (12.4 h vs. 16.2 h, p < 0.001). With misoprostol, more women delivered within 12 hours (60% vs. 32%, p < 0.01) and 24 hours (98% vs. 92%, p < 0.05), spontaneous rupture of the membranes occurred more frequently (34% vs. 20%, p < 0.05), there was less need for oxytocin augmentation (64% vs. 84%, p < 0.05) and fewer additional doses were required (6% vs. 20%, p < 0.05). Although not statistically significant, a lower Caesarean section (CS) rate was observed with misoprostol (8% vs. 12%, p > 0.05) but with the disadvantage of higher abnormal fetal heart rate (FHR) tracings (26% vs. 12%, p > 0.05). From the misoprostol group more neonates were admitted to the intensive neonatal unit, than from the dinoprostone group (14% vs. 6%, p > 0.05). Conclusions Vaginal misoprostol, compared with dinoprostone in the regimens used, is more effective in elective inductions of labor beyond 40 weeks of gestation. Nevertheless, this is at the expense of more abnormal FHR tracings and more admissions to the neonatal unit, indicating that the faster approach is not necessarily the better approach to childbirth.

the preferred pharmacologic agent is oxytocin.[1] INTRODUCTION One of the most common indications is prolonged Induction of labor is carried out for maternal and fetal pregnancy. An important determinant of pregnancy indications. In the absence of a ripe or favorable cervix, a outcome is the timely onset of labor and birth. Prolonged successful vaginal birth is less likely. Therefore, cervical gestation complicates 5% to 10% of all pregnancies and ripening or preparedness for induction should be [2]. assessed before a regimen is selected. Assessment is confers increased risk to both the fetus and mother. accomplished by calculating a Bishop score. When the Thus, there is a growing body of evidence suggesting the elective induction of labor at term gestation can reduce Bishop score is less than 6, it is recommended that a [3]. cervical ripening agent be used before labor induction. perinatal mortality

Among various methods, only the mechanical and Prostaglandin analogues, dinoprostone (PGE2 ) and

surgical methods have proven efficacy for cervical misoprostol (PGE1 ), are commonly used in "induction of ripening or induction of labor. Pharmacologic agents labor" practice for ripening the cervix and stimulating available for cervical ripening and labor induction include uterine contractions in order to achieve vaginal delivery. prostaglandins, misoprostol, mifepristone, and relaxin. Although dinoprostone has been approved by the FDA for When the Bishop score as shown in table 1 is favorable, cervical ripening in women at or near term, misoprostol is Correspondence Address : Masum B Leuva Plot no 671/1 Sector 4-C, Gandhinagar 382004 E-mail id: [email protected]

26 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 not currently approved for such use by the FDA, although performed by one of the resident doctors on duty, who it has the advantages of lower cost, no need for was not involved in managing these women in labor or refrigeration and probably higher efficacy. delivery. The Cochrane Pregnancy and Childbirth Group (2005), Inclusion criteria were: 1) age>18 years old 2) nulliparity, having reviewed 70 randomized studies, concluded that 3) accurate dating of gestation, including crown rump compared with vaginal prostaglandin E2 , vaginal length (CRL) measurements in the first trimester of misoprostol was associated with lower epidural analgesia pregnancy, 4) singleton viable pregnancy, 5) gestational use and fewer failures to achieving vaginal delivery within age≥ 285 days, 6) cephalic presentation, 7) unfavorable 24 hour, but more uterine hyper stimulation as well as cervical status defined as a Bishop score (BS) of≤ 5, 8) [4]. meconium stained fluid Uterine Hyperstimulation is a intact membranes, 9) reactive non-stress test (NST). serious complication of labor induction. It is defined as single contractions lasting 2 minutes or more, or five or Exclusion criteria were: 1) known contraindications to more contractions in a 10 minute period. It can cause receiving prostaglandins, 2) placenta previa, 3) prior impairment to uteroplacental blood flow, and result in uterine surgery and 4) any antenatal complications. uterine rupture, placental abruption and fetal heart rate Gestational age was estimated by ultrasound biometry abnormalities. Most of the studies included in the previous (via CRL measurements in the first trimester of meta-analysis used the 50 mcg dose for misoprostol at a pregnancy) in cases where there was more than 3 days maximum interval of six hours between the repeated difference from that obtained from the last menstrual doses, always resulting in higher rates of period (LMP)[8]. Uterine tachysystole was defined as more hyperstimulation. than five contractions per 10 minutes, uterine hypertonus It is difficult to compare misoprostol with dinoprostone for as when one contraction lasted more than 2 minutes and induction of labor in both complicated and hyperstimulation syndrome as the presence of non- uncomplicated pregnancies, multipara women with reassuring FHR tracing combined with either nulliparous as well as a wide gestational age (GA) range tachysystole or hypertonus. Non-reassuring FHR (37–42 weeks). Moreover, to reduce the risk of side patterns were defined as persistent or recurring episodes effects, one can either decrease the dose of the drug[5] or of severe variable decelerations, late decelerations, prolong the dosage interval.[6] In addition, Alexander et al. prolonged fetal bradycardia or a combination of decreased beat-to-beat variability and a decelerative have recently shown that in prolonged pregnancies it was [9]. not the induction per se that would increase the risk for pattern caesarean section (CS), but patients related risk factors ANST to ensure the well-being of the fetus was performed such as nulliparity and unfavorable cervix and the use of for each patient at the time of recruitment and admission epidural analgesia [7]. to the hospital (at least 285 days of gestation) and one This study was undertaken to compare the efficacy of hour before the application of the prostaglandin. After the vaginal misoprostol (25 mcg) administered at interval of reassessment of the cervical Bishop Score (BS), either 25 four hours with that of vaginal dinoprostone (0.5 mg) mcg misoprostol, or 0. 5 mg dinoprostone was administered at an interval of eight hours maximum three administered in the posterior vaginal fornix. The NST was doses in nulliparous women with an unfavorable cervix repeated one hourly. If the woman was in active labor, the and without pregnancy complications. membranes spontaneously ruptured or the FHR not reassuring, the patient was transferred to the labor room. MATERIAL AND METHODS Otherwise, a second BS evaluation was carried out after 4 hours in misoprostol induction group and after 8 hours in Between May 2011 and June 2012, 100 women were dinoprostone induction group. If the cervix was favorable, recruited for the study: 50 women in the misoprostol group (BS≥ 5), the patient was admitted to the labor ward where and 50 women in the dinoprostone group. All of the oxytocin augmentation was carried out if the uterine women were recruited at Civil Hospital Ahmedabad, a contractions were unsatisfactory and amniotomy was tertiary referral center for high-risk pregnancies, with performed when appropriate. If the cervix was still about 6000 deliveries a year. All participants gave their unfavorable, a second dose of misoprostol or written informed consent after they had been made aware dinoprostone was given and the same evaluation steps as of the purpose of the study. Although the main indication described above were followed. After a total of 8 hours in was prolonged pregnancy, some of the inductions were misoprostol group and 16 hours in dinoprostone group performed at the patient's request after consultation at 40 had elapsed, non-responders were given a third dose of weeks of gestation, (without any medical indications) and prostaglandin. When the third dose was insufficient for only if they had not delivered by the 285th day of gestation. initiating spontaneous labor, a trial of labor was offered The vaginal administration of prostaglandins was with oxytocin infusion and if no progress was achieved

27 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 within 6 hours (based on digital assessment of the BS), The induction-delivery interval was significantly shorter the patient underwent a Cesarean Section. (12 h vs. 16 h, p < 0.001) in the misoprostol group, with The outcome measures were divided into "obstetrical" even less need for a second or third dose (6% vs. 18%, p < and "neonatal". The primary outcome measures were 0.05) compared to dinoprostone. With misoprostol, more time from induction to delivery and incidence of vaginal women delivered within 12 h (60% vs. 32%, p < 0.01) and delivery within 12 and 24 hours; the secondary outcomes almost all of the women delivered within 24 h (98% vs. were the Cesarean Section rate, the need for oxytocin 92%, p < 0.05). In addition, spontaneous rupture of the augmentation, the incidence of meconium stained membranes occurred more often after the administration amniotic fluid, the incidence of uterine tachysystole, of misoprostol (p < 0.05) and there was a reduced need abnormal FHR tracings, maternal morbidity, the for oxytocin augmentation in labor: 64% vs. 84% with admission to neonatal intensive care within 24 hours and dinoprostone (p < 0.05). However, uterine tachysystole (p neonatal arterial cord ph, base deficit. < 0.05)) and meconium stained amniotic fluid (p > 0.05) occurred more often in the misoprostol group as did The Chi square test and Fisher's exact test were used to abnormal heart rate tracing (26% vs.12%, p > 0.05) (Table analyze nominal variables in the form of frequency tables. II). Normally distributed metric variables were tested by the Table III Mode of delivery and indications T-test for independent samples, while non-normally for Caesarean section distributed metric variables were analyzed by the U test. All tests were two-tailed with a confidence level of 95% (p Misoprostol Dinoprostone n=50 n=50 < 0.05). Values are expressed as mean ± standard error (SEM). Vaginal 46(92%) 44(88%) Spontaneous 30(60%) 34(68%) RESULTS instrumental 16(32%) 10(20%) The two groups were comparable in terms of patients' age Caesarean section 4(8%) 6(12%) (28 years vs.27, p > 0.05) and indication for induction Non reassuring FHR 3(6%) 2(4%) (prolonged pregnancy 82% vs.78%, p > 0.05; social 18% Failed induction 0 3(6%) vs. 22 %,) in the misoprostol and dinoprostone groups, respectively. Gestational age (286 days, range: 285–292) Cephalopelvic 1(2%) 0 and the preinduction BS (2.7 ± 0.1) in the misoprostol disproportion group were also comparable to the dinoprostone group Others 0 1(2%) (286 days, range: 285–293) and (2.9 ± 0.1), respectively. In both groups, the majority of women had vaginal Table I Bishop score delivery, 92% with misoprostol, and 88% with score dinoprostone. There was no statistically significant Cervix difference between the two groups with regard to the 0123 Cesarean Section rate (Table III). There were no uterine Position Posterior Midposition anterior - ruptures or other major maternal complications resulting Consistency Firm Medium soft - from the use of either of the prostaglandins. One woman Effacement 0-30% 40-50% 60-70% >80% in each group had delayed discharge due to persistent Dilatation Closed 1-2 cm 3-4 cm >5 cm pyrexia. Station -3 -2 -1 , 0 +1, +2 Table IV Neonatal outcome Total score: 13, favorable score 6-13, unfavorable score 0-5. Misoprostol Dinoprostone Table II Obstetrical Outcomes n=50 n=50 Birth weight 2.7 kg 2.8 kg Misorostol Dinoprostone Stastical n=50 n=50 significance Neonatal 6(12%) 5(10%)

Time from induction to 12 hours 16 hours P<0.001 resuscitation delivery O2 supplementation 4(8%) 3(6%) Delivery <12h 30(60%) 16(32%) P <0.01 Ambu ventilation 1(2%) 2(4%) Delivery <24h 49(98%) 46(92%) P <0.05 Intubation 1(2%) 0 Single dose 47(94%) 40(80%) Apgar score<7at1min 6(12%) 3(6%) Second dose 3(6%) 9(18%) Hyperbilirubinemia 5(10%) 3(6%) Third dose 0 1(2%) Birth trauma 0 1(2%) Oxytocin required 32(64%) 42(84) P<0.05 Perinatal death 0 1(2%)

28 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 More neonates in the misoprostol group had first minute group, whereas vaginal route of delivery was 95% in Apgar scores lower than 7 (12% vs. 6%, p > 0.05), or misoprostol group and 85% in dinoprostone group. needed neonatal resuscitation (12% vs. 10%, p > 0.05) Average dosages required were 1.55 +/- 1.02 in but none of the babies had birth asphyxia. One neonate misoprostol group and 1.30 +/- 0.46 in dinoprostone had meconium aspiration syndrome in misoprostol group. group.All these result were statistically significant. [11]. One neonate in the dinoprostone group had clavicle Even though misoprostol improves the kinetics of labor fracture (Table IV). One perinatal death occurred in during induction in a more efficient way than dinoprostone group due to congenital heart disease. dinoprostone, concerns persist with respect to Table V Admission to Neonatal Intensive intrapartum fetal "wellbeing". In order to avoid uterine Care Unit (NICU) hyperstimulation and abnormal FHR tracings, we used an 8 h interval between the prostaglandin doses. Although Misoprostol Dinoprostone we indeed achieved a low rate of uterine hyperstimulation Admission to NICU 3(6%) 2(4%) syndrome (4% with misoprostol and 2% with dinoprostone, respectively), we still noticed a trend There was no statistically significant difference in the towards a high rate of abnormal FHR tracings during number of neonates admitted to neonatal intensive care induction with misoprostol. Our findings, in accordance within 24 hours after delivery, between the misoprostol with the previous Cochrane metanalysis[12], showed that and dinoprostone groups (6% vs. 4% p > 0.05) (TableV). with misoprostol there was an increased probability of meconium staining of amniotic fluid as well as of uterine DISCUSSION tachysystole and of abnormal FHR tracings. In the Nowadays, induction of labor is more widely used than misoprostol group, the majority of women also underwent ever before. Recent studies have shown that this either a CS or a vacuum operative delivery due to non- increase is mainly due to a rise of inductions for marginal reassuring FHR. If neonatal outcomes such as neonatal or elective reasons. The common indications are elective resuscitation, low Apgar score in the first minute and induction and postdate pregnancy often applied to admittance to the neonatal unit within the first 24 hours [10]. gestations of 40 to 41 weeks Women may experience (none of the above were statistically significant but they distress when labor has not started by the expected date were more frequent with misoprostol) are taken into and obstetricians have to withstand pressure from these account, misoprostol may increase these complications patients as well as the temptation to use prostaglandins in labor. Thus, although our sample size cannot determine earlier. Appropriate evaluation of the pregnancy and safety, misoprostol use is associated with a higher chance consultation with such patients will lead to the correct of admittance to the neonatal unit within 24 hours even in selection of those who will benefit most from a labor the absence of asphyxia. This evidence indicates that the induction, thus eliminating the risk of post-maturity to the faster approach to childbirth is not necessarily the better fetus without inducing fetal distress during labor. one. To the best of our knowledge, the present study is the only Attempting an explanation to the aforementioned side one that compares misoprostol and dinoprostone in such effects of misoprostol use, it appears that the increase in well-homogenized groups. All of the women were clinically relevant adverse effects is not only misoprostol nulliparous with intact membranes and at more than forty related but it may be dose dependent. Lyons et al. have weeks' gestation with no antenatal complications and all recently shown in term pregnant rats that a higher dose of had an unfavorable cervix. In these carefully selected misoprostol is needed to induce PGE2 secretion in the patients, misoprostol at the dose used not only shortened cervix than in the myometrium, and furthermore that EP3 the time between induction and delivery (6vs. 12h), but it receptors (prostaglandin E2 receptors) are differentially also was significantly more effective than dinoprostone. expressed in the myometrium (increased) than in the The positive point was that this result was achieved with a cervix (unaltered) in response to misoprostol[13]. The very low CS rate even in the dinoprostone group, (8%, above findings indicate that misoprostol not only acts and 12%), respectively. A difference of 4% in favor of better on the myometrium than on the cervix, but an even misoprostol, although not statistically significant, might higher dose is needed in order to ripen the cervix. Thus, it have clinical importance in terms of patient health and seems reasonable that increasing the interval between cost effectiveness. The comparative study done by repeated misoprostol doses should reduce the risk of an kulshreshta et al. in 2007 show that mean induction of asynchrony between a well or even hyper-stimulated labor initiation interval was 2.08 +/- 1.46 hours in study uterus and a still not efficiently ripened cervix. Misoprostol group and 2.21 +/- 1.20 hours in dinoprostone group. The probably has a large inter-patient variability in terms of Induction delivery interval was 6.92 +/- 4.01 hours in pharmacokinetics, but it is also probable that the 50 mcg misoprostol group and 12.54 +/- 7.73 in dinoprostone dosage may induce asynchrony between immature cervix

29 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 effacement and uterine contractions, resulting in a more 4. Hofmeyr GJ, Gulmezoglu AM. Vaginal misoprostol for cervical rapid but also more "stressful" labor. Based on these ripening and induction of labor. Cochrane Database Syst findings, we propose, a slight modification of the Rev2003; 1: CD000941 misoprostol protocol used in this study. An initial lower 5. M M Meydanli,E Calişkan , F Burak, M A Narin, R Atmaca, dose of misoprostol (20–25 mcg), followed by 50 mcg International journal of gynecology and obstetrics: the official should be considered in trying to achieve priming of the organ of the International Federation of Gynecology and cervix without inducing such high uterine contractility and Obstetrics. 81(3):249-55. · 1.41. neonatal complications. 6. Agarwal N,Gupta A,Kriplani A,Bhatla N,Parul None, Six hourly vaginal misoprostol versus intracervical dinoprostone for cervical It still has to be mentioned that in many of our participants, ripening and labor induction ,J Obstet Gynaecol Res. 2003 the vertex was not engaged in the pelvic inlet on the day of Jun;29(3):147-51 admittance and this should have been included as an 7. Alexander JM, McIntire DD, Leveno KJ. Prolonged pregnancy: independent risk factor in the initial study design. There is induction of labor and Caesarean births. Obstet Gynecol. 2001; a need for continuous FHR monitoring during labor 97:911–915. doi: 10.1016/S0029-7844(01)01354-0. induction if regular uterine contractions persist. 8. Eberhard Merz, Ultrasound in Obstetrics and Gynecology Volume 1, second edition fully revised, Stuttgart, Germany Georg thieme CONCLUSIONS Verlag 2002.640p. To conclude, vaginal misoprostol appears to be more 9. ACOG technical bulletin. Fetal heart rate patterns: monitoring, effective in inducing labor than conventional methods of interpretation, and management. Number 207--July 1995 (replaces No. 132, September 1989). cervical ripening and labor induction. 25 mcg misoprostol at a 4 hourly interval is more highly effective in promoting 10. Rayburn WF, Zhang J. Rising rates of labor induction: present concerns and future strategies. Obstet Gynecol. 2002; cervical ripening and in inducing labor. However, certain 100:164–167. doi: 10.1016/S0029-7844(02) 02047-1. aspects concerning fetal well being during labor induction remain questionable. The apparent increase in uterine 11. Kulshreshtha S, Sharma P, Mohan G, Singh S, Singh S. Comparative study of misoprostol vs dinoprostone for induction of hyperstimulation is of concern. The studies were not large labor. Indian J Physiol Pharmacol. 2007 Jan-Mar; 51(1):55-61. enough to exclude the possibility of rare but serious 12. Hofmeyr GJ, Gulmezoglu AM. The Cochrane Library. Oxford: adverse effects, particularly uterine rupture, which has Update Software; 2002. Vaginal misoprostol for cervical ripening been reported following misoprostol use. Larger and induction of labor (Cochrane review) prospective studies comparing elective induction to 13. Lyons C, Beharry K, Akmal Y, Attenello F, Nageotte MP. In vitro expectant management after a completed 40-week response of prostaglandin E2 receptor (EP3) in the term pregnant gestation might reveal a subgroup of women, such as rat uterus and cervix to misoprostol. Prostaglandins Other Lipid nulliparous with an unfavorable cervix, who might benefit Mediat. 2003; 70:317–321. doi: 10.1016/S0090 - 6980 (02) from an elective induction, preferably with a 25 mcg 00146-6. misoprostol initial dose.

ACKNOWLEDGEMENTS

The authors would like to thank all of the patients who participated in the trial, the midwifes in the antenatal clinic and the labor ward and the doctors and nurses in the neonatal intensive care unit, whose involvement made this study possible.

REFERENCES

1. Josile L. Tenore, M.D., S.M., . Methods for Cervical Ripening and Induction of Labor

Northwestern University Medical School, Chicago, IllinoisAm Fam Physician. 2003 May 15; 67(10):2123-2128.

2. Arwa Abbas Hussain, Mohammad Yawar Yakoob, Aamer Imdad, and Zulfiqar A Bhutta , BMC Public Health. 2011; 11(Suppl 3): S5. Published online 2011April 13. doi: 10.1186/1471-2458-11-S3-S5

3. Sarah J Stock, Evelyn Ferguson, Andrew Duffy, Ian Ford, James Chalmers,Jane E Norman

BMJ2012; 344doi: 10.1136/bmj.e2838 (Published 10 May 2012) Cite this as: BMJ2012; 344:e2838

30 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 Awareness of Ergonomic Guidelines regarding laparoscopic surgeries, its Practice among Surgeons and Comfort level during and after surgery Dr. Yogendra S. Modi*, Dr. Manoranjan R. Kuswaha**, Dr. Sumit Pukhraj Dave*** * Professor (General Surgery) AMC-MET Medical College, Maninagar, Ahmedabad., ** Associate Professor (General Surgery), ***3rd year resident (General Surgery) N.H.L. Municipal Medical College, Ellise Bridge, Ahmedabad. KEY WORDS : (1) Ergonomic guideline practice. (2) Surgeons comfort. (3) Eye-hand-target axis alignment.

ABSTRACT Study is conducted among the surgeons of various fields like digestive, urological, gynaecological, and thoracic, in three medical colleges at ahmedabad, india. 80 questionnaire were sent out of these 50 surgeons responded with respondent rate of 62.5%. mean duration of laparoscopic surgery practice of above surgeons is 7.8 years. 64% surgeons are aware about the ergonomic guideline regarding laparoscopic surgery, but the practice of it in terms of operating surface (table) height and monitor height is lower. 54% and 4% surgeons are following the guideline in operating surface height and monitor height respectively, this is likely to be related with adjustable operating surface height considering particular surgery and built of the patient and placement of monitor on the cart which have fixed height from the floor. 66% surgeons reported arm and shoulder pain while 32% reported neck pain during or after surgery, but no one need medication for it except one who develop trapezitis . 64% surgeons are often using the 14 inch monitor size while 36%, 26 inch size, among these 82% are comfortable with 26 inch size monitor.

INTRODUCTION Sensorial ergonomics, manipulation and visualisation Minimally invasive surgery (MIS) is being widely used in improve precision, dexterity and confidence while various fields of surgery like digestive, urological, physical provide comfort for surgeons. Together these thoracic, gynaecological etc. Minimal invasive surgery is two elements of ergonomics improve safety, have better technically more demanding and need more outcome and reduce the stress(5). concentration to perform the task than open surgery. Proper design of instruments and operating room is Ergonomic integration and suitable laparoscopic critical to avoid human error during MIS(6). During MIS, operating room environment are essential to improve surgeons hold posture that is more static than in open efficiency, safety, and comfort for operating team(1). surgery likely to related with indirect vision, less efficient Follow of ergonomic principles are require for better work instruments and mentally merging separate visual and results in fields which demand productivity. Word mechanical coordinate system in real time. Static ERGONOMIC originate from greek word ergon (labor) postures have been demonstrated more disabling and and nomog(natural law) that reveal 'knowledge harmful than dynamic one because the muscles and concerning the law of human labour'(2). tendons form lactic acid and toxins when held in static position (7). Follow of suboptimal ergonomic principles expose surgeons to physical discomfort during and after Goal of proper posture is comfort, efficiency of laparoscopic surgery(3). movements and minimization of the risk of musculoskeletal injuries to the surgeons (6). HAWTHORNE EFFECT- which has been found applicable to most scientific assessment of human Ability to achieve this goal is determined by : function and hence an integral knowledge of this aspect is 1. Height of the operating surface (table) essential for ergonomic purposes(4). 2. Position of visual display (monitor)

Correspondence Address : Dr. Sumit Pukhraj Dave E-11, Doctor Quarter's, Vadilal Sarabhai General Hospital Ellise Bridge, Ahmedabad- 380006. e-mail: [email protected]

GMJ 31 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 3. Foot pedal location 4. Selection of hand instruments Optimal height of operating surface is must for the 'EYE- HAND-TARGET AXIS' alignment. If operating surface is high, the body unconsciously compensates by elevating the ipsilateral shoulder. This restores the right angle at the elbow but produce and undue amount of strain at the shoulder and arm. The surgeon usually is unaware of this and has no discomfort during short duration surgeries. But if the surgery is prolonged, neck, arm and shoulder strain develop. The obvious solution is to lower the Fig.1-layout of laparoscopic surgery operating room operating surface till a comfortable height achieved. (table, monitor, ceiling mounted boom system)(10) Studies have shown that optimal height of instrument handle is at elbow height or 5 cm above it(8). AIM OF THE STUDY Tableheight = surgeon's height*0.49 Study the awareness of the ergonomic guidelines and its practice in terms of operating surface (table height) and Optimum operating surface height is must for the proper monitor height and comfort level of surgeon during and port placement along with the task performance. Ports are after surgery introduced by keeping in mind BASEBALL-DIAMOND CONCEPT (9). MATERIALS AND METHODS The study is conducted among the surgeons of the 3 1. Telescopefixation between working instruments 2. Maintain elevation angle of 30 degree medical colleges of Ahmedabad, India : B.J.Medical 3. Maintain manipulation angle 60 degree college, N.H.L.Municipal Medical college and AMC-MET 4. Maintain azimuth angle 30 degree medical college. Misalignment in the 'EYE-HAND-TARGETAXIS' because 80 questionnaires were sent to the surgeons of different of limited freedom in monitor positioning is recognised as specialties.Among these 50 responded. an important ergonomic drawback during MIS. Duration of practising as laparoscopic surgeon was Realignment of the same improves personal values of considered. comfort and safety as well as procedural values of Operating room factors considered were Operating effectiveness and efficiency (9). Preferred viewing angle surface (table) height, Monitor height, Monitor size often for office video terminal display is 10 to 25 degree below using and Monitor size comfortable with(11). the horizontal from users eye level ( standard video Physical discomfort factors considered were neck pain, monitor are of CRT or LCD kept on separate low cart on shoulder and arm pain, whether it needs medication or ceiling mounted boom system(7)). not(11).

Questionnaire NAME : DESIGNATION: DEPARTMENT : INSTITUTION : DURATION OF PRACTICE : 1. HEIGHT OF MONITOR : - A) AT EYE LEVEL ____ B) ABOVE EYE LEVEL ____ C) BELOW EYE LEVE ____ 2. SIZE OF MONITOR YOU ARE USING :- A) 14" ____ B) 26" ____ C) >26" ____ 3. SIZE OF MONITOR YOU ARE COMFORTABLE WITH :- A) 14" ____ B) 26" ____ C) >26" ____

32 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 4. HEIGHT OF TABLE :- A) AT UMBILICAL LEVEL ____ B) ABOVE UMBILICAL LEVEL ____ C) BELOW UMBILICAL LEVEL ____ 5. DO YOU FEEL NECK PAIN DURING OR AFTER SURGERY :- YES ____ NO ____ WHETHER PAIN NEED MEDICATION :- YES ____ NO ____ 6. DO YOU FEEL SHOULDER OR ARM PAIN DURING OR AFTER SURGERY :- YES ____ NO ____ WHETHER PAIN NEED MEDICATION :- YES ____ NO ____ 7. ARE YOU AWARE ABOUT ERGONOMIC GUIDLINES REGARDING LAPAROSCOPIC SURGERY :- YES ____ NO ____

RESULTS Height of monitor : 4% surgeons are using monitors (center) below the eye level. Respondent characteristic : Respondent rate was 62.5%. The characteristic of the respondent considered was the duration of laparoscopic surgical practice which was found as mean duration of 7.8 years. Awareness : 64% surgeons are aware about the ergonomic guidelines regarding laparoscopic surgery.

Bar chart-2

Size of monitor often using : 64% often using monitor of 14 inch size while 36% 26inch.

Pie chart-1

Operating surface (table) height : 54% of surgeons are performing on the surface below the umbilical level.

Bar chart-3 Bar chart-1

33 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 Size of monitor comfortable with : 82% surgeons are and monitor height respectively. The cause of the lower comfortable with 26 inch size monitor. practice and disparity in practice, among both the parameter has not been studied but, likely to be related with the adjustable operating surface height considering particular surgery and built of the patient and placement of monitor on the cart which have fixed height from the floor. Lower practicing rate might be due to the poor layout of operating room, which demand specially designed operating table for laparoscopic surgery and ceiling mounted boom system for placement of monitor at two different locations, one in front of surgeon and side of patient and another in front of camera assistant to achieve the desirable alignment of EYE-HAND-TARGETAXIS. 66% surgeons reported arms and shoulder pain while 32% reported neck pain during or after surgery but no one Bar chart-4 need any kind of medication fot it except one who devlop Neck pain during or after surgery : 32% experience pain in trapezitis due to maladjusted monitor height ,after initial 5 neck but no one need medication for it. years of laparoscopic surgery practice. 64% surgeons are often using the 14 inch monitor size while 36%, 26 inch size; among these 82% are comfortable with 26 inch monitor; likely related with larger field of vision. Minibreaks during surgery are essential to break the static posture and achieve an optimal comfort level to improve work efficiency and prevent human error(7). CONCLUSION Despite awareness of ergonomic guideline among surgeons, its practice is lower than expected. Surgeons experience more arms and shoulder pain than neck pain but doesn't required medication. 26 inch Pie chart-2 monitor is more comfortable than 14 inch monitor REFERENCES Arm or Shoulder pain : 66% experience arm or shoulder 1 supeAN et al. j.minimacesssurg.2010apr;6 pain. 2 lsgl wauben; m.a.vanveelen; d. Gossot; r.h.m. goossens; application of ergonomic guideline during minimally invasive surgery. 3 Vicdan sari thodoor; e.nieboer; mark e vierhout; dick f. Stegeman; kirsteten b. Kluivers; operating room as a hostile environment for surgeon. 4 hanson D.L. evaluation of the HAWTHORNE EFFECT on physical education research(pub med) 5 stylopoulos N, rattner D, robotic eggonomics SCNA 2003 (pub med) 6 Ramon berguer m.d. ; ergonomics in laparoscopic surgery; the sage manual;2006 7 Ramon burguer md; ergonomics and laparoscopic surgery-2nd edition 8 m.j.wandet; w.j.h.j.meijerink; c.hoff; e.r.totte; j.pen pierre; optimal ergonomics for laparoscopic surgery in minimally invasive surgery suites-a review and guidelines Pie chart-3 9 gurvinder kaur; role of OT table height on the task performance of minimal access surgery; world journal of laparoscopic DISCUSSION surgery, January-april 2008 1(1):49-55 10 www. acssurgery. com/ acssurgery / secured / figtabpopup . 64% surgeons are aware about the ergonomic guideline action ? bookid = part 10_ch23_fig1 & type=fig regarding laparoscopic surgery while 54% and 4% are 11 Surgery update 2012, proceedings of department of surgery practicing it in terms of operating surface (table) height MAMC new delhi; ergonomics in laparoscopic surgery.

34 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 Sero prevalence of HBV, HCV, HIV and syphilis among blood donors at a tertiary Care Teaching Hospital in Western India Dr. Nirali Shah*, Dr. J.M.Shah**, Dr. Preeti Jhaveri***, Dr. Kazoomi Patel****, Dr. C.K.Shah*****, Dr. N.R.Shah****** *1st Year Resident, Pathology Department, Smt. NHL Municipal Medical College, **Associate Professor, ***Assistant Professor,**** ,***Professor, ****Professor & Head, Pathology Department, Smt. NHL Municipal Medical College,Ahmedabad-6, India.****Research Fellow, GCRI,Ahmedabad KEY WORDS : (Seroprevalence, HIV, HBsAg, HCV, Syphilis, Voluntary, Replacement Blood Donors)

Aims : This study is conducted to evaluate the sero-prevalence of HBV, HCV, HIV and syphilis among blood donors in V.S. General Hospital,Ahmedabad along the duration of seven and a half years. All blood units received from replacement as well as voluntary blood donation at Blood Bank, Sheth V.S. General Hospital , Ahmedabad, Gujarat State, India during the period from January 2006 to July 2013 were selected for the study. Materials & Methods : HBV, HCV and HIV were tested by ELISA methods approved by NACOin voluntary as well as replacement blood donors. RPR was carried out for screening of syphilis. Results : The seroprevalence of HIV, HBV, HCV and syphilis was found to be 0.154%, 0.887%0.101%and 0.22% respectively in voluntary blood donors as against the figures of 0.179, 1.16%, 0.123 and 0.26% being the seroprevalence of HIV, HBV, HCV and syphilis in replacement blood donors. It is clear that seroprevalence of HIV, HBV, HCV and syphilis in replacement blood donors is higher than that in voluntary blood donors which is an expected finding. Also the trends of TTIs in both blood donor groups was studied over the years and some interesting facts emerged , particularly with regards to seroprevalence of syphilis in blood donors which showed an increasing and slightly fluctuating trend since year 2009. Conclusion : Voluntary blood donors have been found to be safer than replacement blood donors vis-a-vis markers for HIV, HBsAg, HCV but syphilis shows an increasing prevalence over the years in both blood donor groups since 2009. This may be reflective of changing life style and more open social norms. But this later finding emphasises the ever present need for adopting voluntary blood donation. More detailed history regarding sexual exposure of blood donors is also advocated.

AIMS & OBJECTIVES The report of the US Institute of Medicine entitled “To err is 1. To study the seroprevalence of transfusion human” [Konh LT et al,1999] stated that as many as transmitted infections amongst voluntary as well as 98,000 people die each year needlessly due to 2 replacement blood donors at Blood Bank, Sheth preventable medical errors. Obviously, the complications V.S.General Hospital ,Ahmedabad-6. arising out of improperly tested/ screened blood units before transfusion are included as integral part of such 2. Yearly comparison and study of the trend of mistakes. incidence of HIV, HBV, HCV & Syphilis positive cases. It should be obligatory on those who are involved in transfusion of blood to a patient for saving his life, that the 3. Comparison with similar other studies. blood transfusion does no harm to the patient.3 Morbidity INTRODUCTION and mortality resulting from transfusion of infected blood It is a well known fact that transfusion of blood and blood have far reaching consequences, not only for the components as a specialized modality of patient recipients themselves, but also for their families, their management has been saving millions of lives worldwide communities and the wider society.4 Only continuous each year.Amongst the undesirable complications arising improvement and implementation of donor selection, out of transfusion of blood and blood products, sensitive screening tests and effective inactivation transmission of certain infections (TTIs) like HIV, Hepatitis procedures can ensure the elimination, or at least B and C and syphilis are most significant for the long term reduction of the risk of acquiring TTIs.5 detrimental side effects. Meticulous pretransfusion India is the second most populous nation in the world. The testing and screening particularly for transfusion 1 Indian subcontinent is classified as an intermediate transmissible infections (TTI) is the need of the hour Hepatitis B Virus (HBV) endemic (HBsAg carriage 2-7%) Correspondence Address : Dr. Nirali Shah 47,”Shivkripa”, Chaitanyanagar Society, Ahmedabad-380014. E Mail : [email protected].

GMJ 35 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 zone and has the second largest global pool of chronic Hepatitis B surface antigen (HBsAg) was tested by 3rd HBV infections. India has a population of more than 1.2 generation ELISA, HIV(1and 2) were tested by 3rd &4 th billion with 5.7 (reduced to 2.5) million Human generation ELISA& Hepatitis C virus (HCV) was tested by Immunodeficiency Virus (HIV) positive, 43 million HBV 3rd generation ELISA methods using NACO approved positive and 15 million HCV positive persons. A recent commercially available kits. Screening for syphilis was study by Pahuja et al in 2007 revealed alarming high done by Rapid Plasma Reagin (RPR)method. seroprevalence of HIV, anti-HCV, and HBsAg (0.56%, Donors were selected by taking history, clinical 0.6%, and 2.23%, respectively) among blood donors of a examination (strictly following donor's selection criteria) metropolitan city like Delhi.6 to eliminate professional donors and including donors We report the trends in the seroprevalence of Hepatitis B who gave voluntary written consent for screening of their (HBV), Hepatitis C (HCV), Human Immunodeficiency blood for TTIs. A detailed pre-donation questionnaire was Virus (HIV) and syphilis over a period of seven and a half included in donor registration form. Information regarding years from January 2006 to July 2013 in a tertiary care risk factors like history of surgery, previous illness, hospital based study. hospitalization, blood transfusion, occupation, high risk MATERIALS AND METHODS behaviour and tattoo marks was collected. All the reactive samples were repeat tested before labelling them sero- Duration of study was from January 2006 to July 2013. All positive and respective blood units were discarded as per blood donors (including voluntary and replacement blood standard protocols. donors) coming to donate blood either at Blood Bank, Sheth V.S.G.Hospital, Ahmedabad as well as at various RESULTS blood donation drives organised by blood bank were A total of 92,778 apparently healthy adult donors were included in this study. screened during the study period. Among them 62, 097 92,778 Serum Samples from Replacement and Voluntary (66.9%) were voluntary blood donors and 30681 (33.1%) Donors were tested for prevalence of markers for TTIs were replacement blood donors. Table 1 shows the viz., HIV, HBsAg, HCV antibody & RPR for syphilis. gender distribution in both donor groups.

Table 1 : Year & Gender wise break up of Blood Donors

YEAR VOLUNTARY REPLACEMENT TOTAL DONORS DONORS MFTOTALM F TOTAL Total Blood (Voluntary) (Replacement) Donors (Both Groups) 2006 3997 476 4473 8672 79 8751 13,224 2007 7574 357 7931 6458 31 6489 14,420 2008 5557 397 5954 5737 35 5772 11,726 2009 9042 299 9341 1471 01 1472 10,813 2010 9301 257 9558 1701 16 1717 11,275 2011 9736 232 9968 2462 12 2474 12,442 2012 9163 398 9561 2336 16 2352 11,913 2013 UP TO JULY 5255 56 5311 1648 06 1654 6985 GRAND TOTAL 59625 2472 62097 30485 196 30681 92778

Table 2 : Distribution of sero-positive cases INFECTIONS Voluntary donors Replacement TOTAL (Total no. 62097) donors (Total no. 30681) (Total no.92778) HIV 96 (0.154%) 55 (0.179%) 151(0.162%) HBV 551 (0.887%) 356(1.16%) 907(0.977%) HCV 63 (0.101%) 38(0.123%) 101(0.108%) RPR (Syphilis) 138(0.22%) 80 (0.26%) 218(0.234%)

36 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 The seroprevalence of HIV, HBV, HCV and syphilis was Females comprised of only 3.98% in voluntary blood found to be 0.154%, 0.887%0.101%and 0.22% donor group and 0.63% in replacement blood donor respectively in voluntary blood donors as against the group. Hence only male donors of both groups were figures of 0.179, 1.16%, 0.123 and 0.26% being the included to find out % seroprevalance of TTIs for the seroprevalence of HIV, HBV, HCV and syphilis in purpose of valid and meaningful statistical analysis. The replacement blood donors. year wise trend of seroprevalance shown in various graphs has thus been derived from the data from male donors only in both the groups.

Table 3 : Year Wise Trends of Seroprevelance of TTIs:

YEAR HIV HBsAg HCV VDRL VOL. VOL. REPL REPL VOL. VOL. REPL REPL VOL. VOL. REPL REPL VOL. VOL. REPL REPL (Male) (Female) (Male) (Female) (Male) (Female) (Male) (Female) (Male) (Female) (Male) (Female) (Male) (Female) (Male) (Female) 2006 07 0 25 0 36 01 134 09 02 01 20 01 05 0 40 0 (0.175%) (0.288%) (0.9%) (0.21%) (1.55%) (1.89%) (0.05%) (0.21%) (0.23%) (3.22%) (.12%) (0.46%) 2007 12 0 18 0 58 0 56 0 05 00 10 0 05 0 09 0 (0.158%) (0.27%) (0.76%) (0.86%) (0.06%) (0.15%) (0.06%) (.13%) 2008 04 0070410660050080010040 (.07%) (.12%) (0.73%) (1.15%) (0.08%) (0.13%) (0.01%) (0.06%) 2009 17 0060770160050020200080 (0.18%) (0.4%) (0.85%) (1.08%) (0.05%) (0.13%) (0.2%) (0.5%) 2010 11 00208701302070030100040 (0.11%) (0.11%) (0.93%) (0.76%) (12.5%) (0.07%) (0.17%) (0.1%) (0.23%) 2012 05 0050970270080020260090 (0.05%) (0.21%) (1.05%) (1.15%) (.08%) (0.08%) (0.28%) (0.38%) 2013 110050620150100040170060 (Upto (0.2%) (0.3%) (1.17%) (0.91%) (.19%) (0.24%) (0.32%) (0.36%) July 2013)

Graph 1: HIV positivity amongst Voluntary & real increase in prevalence in the society. Again the peak in the Replacement Donors prevalence of HIV in the year 2009 correlates well with other sexually transmitted disease (syphilis) in the same year.

Graph 2 : HBs Ag positivity in Voluntary & Replacement donors

There seems to be a peak in the prevalence of HIV in the year 2009 otherwise it has shown more or less a steady pattern from 2006 to 2012. There seems to be an increase in HIV positivity which runs parallel to the increase in HCV positivity in current year (from January to July, 2013) Ref. Graph 3. The Barring the year 2006 when HBsAg positivity is the reason for more HCV positivity might be related to the maximum, it has remained almost uniform in other years availability of better diagnostic kits or else could represent a and there is no significant shift in the current year. The

37 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 disturbing trend here is a gradual and steady increase in the living style of people (when such an increase is seen in the positivity rates of HBs Ag in voluntary blood donors association with increase in HIV positivity). The other from year 2008. This might be reflective of asymptomatic putative reasons may be the testing material available in cases of Hepatitis B in the society and may need attention the market for HCV testing. Data pertaining to these years from health authorities. in other studies may throw more light. Graph 3 : HCV Positivity in Voluntary & Graph 4 : VDRL Positivity in Voluntary & Replacement Donors Replacement donors

HCV positivity is showing two peaks at both the ends of There is a constant difference between the seropositivity study period i.e. year 2006 and year 2013.Increasing of RPR amongst voluntary and replacement donors; the prevalence of HCV in both donor populations may be prevalence is justifiably higher in replacement donors. either a real seasonal variation or variation dependent on Association with higher prevalence of HIV antibodies in year 2009 has been discussed in earlier paragraphs.

Table 4 : TTI prevalence in India Comparison of TTI prevalence rate in different parts of India 1 Place HIV% HBsAg % HCV% SYPHILIS% Reference Ludhiana 0.084 0.66 1.09 0.85 Gupta N. et al (2004) 12 Delhi 0.56 2.23 0.66 Pahuja S et al(2007) 8 Lucknow (UP) 0.23 1.96 0.85 0.01 Chandra T et al (2009) 10 Southern 0.3 1.7 1.0 0.9 Arora D et al Haryana (2010) 7 West Bengal 0.28 1.46 0.31 0.72 Bhattacharya P et al (2007), Bangalore, 0.44 1.86 1.02 1.6 Srikrishna A Karnataka et al (1999) ,11 Present study 0.16 0.98 0.11 0.23 (2013)

Comparing our data, it seems that barring HCV, all other geographical distribution or declining rate of HCV viral markers were more or less correlating with the data positivity in healthy population. The wide variations of from various studies carried out at various centers in HCV seroprevalance in different studies in India might be Delhi, Ludhiana, Haryana, U.P., West Bengal and due to the use of different generation of ELISA test kits, Bangalore. Our study reveals an average overall having different sensitivities and specificities. Various prevalence of HCV antibodies in Blood Donors serum as studies have reported an international HCV prevalence being 0.11% (ranging from about 0.05% in 2006, 2009, range of 0.42–1.2%. 8 2011 to a maximum of 0.24% in the current year 2013) which is significantly lower than other regions of India. The reason for this may be either a particular

38 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 DISCUSSION Voluntary donors. Our study is comparable to other With every unit of blood, there is 1% chance of transfusion studies carried out in India. Efforts should be made to associated problems including TTI. The risk of TTI has increase the number of voluntary donors and reduce declined dramatically in high income nations over the past replacement donations to a minimum. Motivation and two decades, but the same may not hold good for the recruitment of potential local blood donor population developing countries. The national policy for blood would help in effective implementing of voluntary blood transfusion services in our country is of recent origin and donation program in the community. the transfusion services are hospital based and The major concern in transfusion services today is fragmented. Voluntary donors (VD) are motivated blood increased seropositivity among Replacement Donors for donors who donate blood at regular intervals and HCV, HIV, HBsAg and syphilis. With the advent of nucleic replacement donors (RD) are usually one time blood acid amplification techniques (NAT), western countries donors who donate blood only when a relative or a friend have decreased the risk of TTI to a major extent. But the is in need of blood. 1 cost-effectiveness of NAT is poor. The NAT has added Various studies in India about the seroprevalence of HCV benefits but its high financial cost is of concern, especially have shown data ranging from the lowest (0.31% ) in the in underdeveloped countries like India.Apart from NAT for study by Bhattacharya et al in 2007 to the higher one of donor screening, other factors such as public awareness, 1 vigilance of errors, educational and motivational 1.09% (Gupta et al, 2004). A significantly lower programs is sure to help in decreasing the infections. prevalence of 0.11% has been noted in our study. But at the same time an increase in HCV positivity has been REFERENCES found in current year which may be attributed in part to 1. Seroprevalence and Trends in Transfusion Transmitted Infections availability of better diagnostic kits with higher sensitivity. Among Blood Donors in a University Hospital Blood Bank: A 5 Year Study: P. Pallavi , C. K. Ganesh , K. Jayashree , G. V. Sexually transmitted infections are widespread in Manjunath: Indian J Hematol Blood Transfus (Jan-Mar 2011) developing countries and constitute a major public health 27(1):1–6 2. Managing Clinical Laboratories: Monitor and Control Lab Errors problem. The VDRL reactivity in our study was 0.23% to improve Lab Performance :Poonam Trivedi, Nailesh Shah, K.V. which is significantly lower value as compared to other Ramani, W.P.No. 2011-11-02, November 2011 studies in India as shown in table 4. There has been a 3. Dr. R. K. Sarma ,Transfusion medicine ,WHO manual,2nd edition constant difference between seropositivity for RPR 2003. 143-172. amongst voluntary and replacement blood donors. 4. World Health Organization (WHO). Blood Safety Strategy for the African Region. Brazzaville, World Health Organization, Regional The current practice of selection of voluntary donors over Office forAfrica (WHOAFR /RC51/9 Rev.1). 2002 replacement donors to meet with the need for blood in a 5. Tiwari BR, Ghimmire P, Karki S, Raj Kumar M, 2008. general hospital coupled with more numbers of voluntary Seroprevalence of human immunodeficiency virus in Nepalese blood donors: A study from three regional blood transfusion donor drives in the community as well as availability of services.Asian Journal of Transfusion Science,2: 66-68. better testing reagents (particularly for HIV and HCV 6. Giri PA, Deshpande JD, Phalke DB, Karle LB : Seroprevalence of infections) is sure to lower down the threats of transmitting transfusion transmissible infections among voluntary blood TTIs to patients via transfusion of blood and blood donors at a tertiary care teaching hospital in rural area of India: J.Fam. Med. Primary Care 2012: 1:48-51 products. As is apparent from the results of present study 7. Arora D,Arora B, KhetarpalA(2010) Seroprevalence of HIV, HBV, the results of which are comparable to other studies in HCV and syphilis in blood donors in Southern Haryana.Indian J India, voluntary blood donors have significantly lower Pathol Microbiol 53:308–309 rates of prevalence for markers of TTIs as compared to 8. Pahuja S, Sharma M, Baitha B, Jain M (2007) Prevalence and replacement blood donors. Awareness of general trends of markers of hepatitis C virus, hepatitis B virus and human immunodeficiency virus in Delhi blood donors. A hospitalbased population about voluntary regular blood donation should study. Jpn J Inf Dis 60:389–391 be created to minimize the chances of spreading 9. Bhattacharya P, Chakraborty S, Basu SK (2007) Significant transfusion transmitted infections. Replacement donors increase in HBV, HCV, HIV and syphilis infections among blood carry a relatively higher risk of transfusion transmitted donors in West Bengal, Eastern India 2004–2005. Exploratory screening reveals high frequency of occult HBV infection. World J infections due to chances of missing professional donors Gastroenterol 13:3730–3733 during donor screening procedures. Hence blood from 10. Chandra T, Kumar A, Gupta A (2009) Prevalence of transfusion replacement donors should be accepted only in cases of transmitted infections in blood donors: an Indian experience.Trop dire emergencies when transfusion of blood or blood Doct 39:152–154 Indian J Hematol Blood Transfus (Jan-Mar 2011) 27(1):1–6 5 products would be life saving. 11. Srikrishna A, Sitalakshmi S, Damodar P (1999) How safe are our CONCLUSION 21. Garg S, Mathur DR, Gard DK (2001) Comparison of seropositivity of HIV, HBV, HCV and syphilis in replacement and As is apparent form the results of present study, higher voluntary 44:409–412 Incidence of Transfusion Transmissible infections have 12. Gupta N, Kumar V, Kaur A (2004) Seroprevalence of HIV, been observed among Replacement donors compared to HBV,HCV and syphilis in voluntary blood donors. Indian J Med Sci 58:255–257.

39 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 Increasing trend of HCV reactivity in healthy blood donors and multitransfused thalassemia patients of Gujarat State Dr. Sangita D. Shah*, Dr. M. D. Gajjar**, Dr.Nidhi M. Bhatnagar*** *Assistant Professor, **Professor and Head, ***Associate professor IHBT dept. B.J.Medical College, Civil Hospital, Ahmedabad. Department of Immunohematology and Blood Transfusion, B-2, Civil Hospital, B.J. Medical College, Ahmedabad.

KEY WORDS : Trend of Hep C infection, Blood donors, Thalassemia patients

Background and Aim : Hepatitis C is transmitted only by blood and blood products, so it is very important to study its prevalence in blood donors. Recently, prevalence of infection has increased. This is alarming as Hepatitis C infection progresses to chronicity and it is not a vaccine preventable disease. This study aims to determine the HCV reactivity trend in Gujarat state and its prevalence in multipully transfused thalassemia patients. Materials and methods: In current study 184238 healthy donors have been screened who have donated blood at the IHBT department, civil hospital,Ahmedabad between 2002 t0 2011. 210 beta thalassemia major patients were also screened for anti HCV who are registered in civil hospital Ahmedabad. Test results of all blood samples such as HCVAntibody, HIVAntigen andAntibody, HbsAg(Hepatitis B surfaceAntigen)Antigen and VDRLAntibody were analysed and documented. (Thalassemia patients were not tested for syphilis.) Results: It was observed that Hep B infection was the most common among all the diseases during whole study (2002-2011). From 2003 onwards Hep B showed a decreasing trend, with prevalence peaking in 2003 (1.67%). The present study revealed that HIV infection was also showing same decreasing pattern. The infection of syphilis was not showing any pattern. Hep C infection showed high prevalence year 2003(0.63%) & 2004(0.75%). During year 2005 (0.22%),2006 (0.21%) and 2007 (0.22%) it showed steady pattern. It shows a steady increase with the passing years (2008-2011). Total of 210 beta-thalassemia major patient 1 patient (0.47%) was Hep B reactive, 3 patients (1.42%) were HIV reactive and 62 patients (29.52%) were Hep C reactive which is very high. The results also show increasing prevalence of infection with increasing age i.e. increasing number of transfusions. Conclusion: To reduce the incidence of HCV infection stringent donor screening should be adopted along with screening of donor with more sensitive 4th generation ELISA methods.

INTRODUCTION asymptomatic disease.3 HepC is major cause of chronic Hepatitis C Virus (HCV), first identified in 1989,causes a active hepatitis, hepatocellular carcinoma, and liver 4 slowly progressive disease affecting about 170 million cirrhosis. Among HIV infected people, mitochondrial (3%) people world wide.1,2 More than three million new dysfunction in hepatocytes and other infected cells is a cases of infection are reported annually,and leading cause of cellular death. epidemiological studies indicate a wide variation in its Thalassemia is an inherited hemoglobinopathies prevalence patterns in different continents and countries.2 disorder.5,6 Blood transfusion is a necessary treatment for In India, the hepatitis C screening test, i.e., HCVAb ELISA these patients. However blood transfusion has its own test became obligatory for blood donation from 1998 and side effects. One major adverse effect of blood it was implicated in our institute since then. transfusionistransfusion transmitted infections, 7,8 In a vast country like India, a survey of blood transmissible especially hepatitis C. diseases in the country as a whole is very difficult. The study was designed to fulfil two objectives. The first Individual epidemiological surveys of each state may help was to determine the increasing prevalence of HCV us to understand the seriousness of the problem and the among blood donors over the last ten years (2002-2011) changing trends. Among the blood transmissible in Gujarat State by testing samples for HCV Antibody, HIV diseases, hepatitis B (HepB) and hepatitis C (HepC) (both Antigen and Antibody, HbsAg Antigen, VDRL Antibody. caused by viruses of the family Hepadnaviridae) , HIV ( The second was prevalence of HCV infection in Human Immunodeficiency Virus ) and syphilis (caused by thalassemia patient who have had multiple transfusions. Treponemapallidumsubsp.pallidum) are major public MATERIAL & METHOD health problems in developing countries. HepB is transmitted parentally and causes either symptomatic or A total of 184238 blood samples were collected from Correspondence Address : Dr. Sangita D. Shah 5 - Mevavala Nagar, Opp. Gopalak Soc., Kiranpark Road, Nava Wadaj; A'bad-380013. [email protected]

40 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 blood donors who donated blood to the IHBT department, Ahmedabad. From table 3 we can see that, among them 1 civil hospital, Ahmedabad between 2002 to 2011. The patient (0.47%) was HepB reactive, 3 patients population under study included people of diverse (1.42%)were HIV reactive and 62 patients (29.52%) were backgrounds,cultures, and lifestyles. Blood samples HepC reactive which is very high. were collected from blood donors within the agegroup of From table 4 we can observe that in 0-3years age group, 18-55 years. Samples were also taken from blood Hep C reactive patients were 07 (3.33%), not a single donation camps. patient was hep B and HIV reactive. Between 4-6 years of Two hundred ten beta– thalassemia major patients age, hep C reactive patients were 12 (5.71%). HIV registered in a civil hospital Ahmedabad were included in reactive and Hep B reactive patients were not found. the study. All patients were under a hypertransfusion Between 7-9 years of age, hep C reactive patients were18 regimen and treated with regular transfusion of packed (8.57%) and HIV reactive patient was only 01(0.47%). red blood cells,at an interval of about three weeks. All Again there was no Hep B reactive patient. In 10 to 12 patients were tested for TTI after obtaining informed years age group Hep B reactive patient was 1(0.47%), 25 consent from the guardians of the patients. (11.90%) patients were Hep C reactive and HIV reactive The most sensitive and specific ELISA test protocol was patients were 2(0.95%). used to establish the diagnosis. All the samples were DISCUSSION tested for HCV Antibody, HIV Antigen and Antibody, Transfusion-dependent patients are more prone to HbsAgAntigen, VDRLAntibody. acquiring various transfusion-transmitted infections such Serum samples were tested by using an enzyme immune as Hepatitis B Virus (HBV), Hepatitis C Virus(HCV), assay (EIA) for HCV antibodies,HbsAg Antigen, HIV Human Immune Deficiency Virus (HIV), syphilis and Antigen /Antibodies and by using Rapid test for Syphilis many more.9 However, HBV and HIV can be transmitted, according to the manufacturer's instructions.Reactive except blood transfusion, from person to samples were retested for 4 times for confirmation by the person,especially hepatitis B, which is transmittable from same kit and repeat testing done by 2nd kit. Thalassemia tears, urine, etc.10,11 Most of those who are HCV positive patients were not tested for syphilis. have a history of parenteral risk such as a history of OBSERVATION transfusion or administration of blood products or of intravenous drug abuse. There is little evidence for sexual In this study we have assessed total of 184238 donors or perinatal transmission of HCV and the natural routes of who donated blood to the IHBT department, civil hospital, transmission are yet to be identified.12 Ahmedabad between 2002 to 2011. Among them, 1957donors were found to be seropositive for Hep B, a Current data suggest that about 50% of infections with prevalence of 1.06%. The seroprevalence of Hep C was HCV progress to chronicity. Histological examination of found to be 0.32%, with the total number of cases being liver biopsies from asymptomatic HCV-carriers reveals 599. The frequency of HIV was 0.33%, with a total of 614 that none has normal histology and that up to 70% have cases. Infection with syphilis was found in 1297 cases, chronic active hepatitis and/or cirrhosis. Whether the giving a prevalence of 0.73%. virus is cytopathic or whether there is an immunopathological element remains unclear. HCV From table 1 and chart 1 we can observe that Hep B infection is also associated with progression to HCC.12 infection was the most common among all the diseases during whole study(2002-2011). It showed a relatively low Hep C poses a threat to society due to its increasing trend. prevalence in the year 2002. From 2003 onwards Hep B Judging by the seroprevalence rates for the last seven showed a decreasing trend, with prevalence peaking in years, it appears to be more of a public health challenge 2003 (1.67%). The present study revealed that HIV than HIV or even Hep B which showed decreasing trend in infection was also showing the same pattern. It was the population studied. And among hepatitis infections highest in 2003 ( 0.52%) and has decreased during recent HepB is vaccine preventable but there is no vaccine for years. The infection of syphilis was not showing any HepC infection.The trend of HIV infection is also pattern. The highest prevalence was seen in year 2008 decreasing due to increased HIV awareness. (1.97%) and the lowest was seen in year 2004 (0.16%). The present study was compared with data of other Hep C infection showed high prevalence year studies. In our study the trend of Hepatitis B and HIV 2003(0.63%) & 2004(0.75%). During year 2005 (0.22%) infection is decreasing. In study by Arpitachatterjee ,2006 (0.21%) and 2007 (0.22%) it showed steady et.al.also the trend of Hepatitis B and HIV infection is pattern. It shows a steady increase with the passing years decreasing but the prevalence of Hepatitis B is lower than (2008-2011). our study.3 In both studies the trend of Hep C is increasing. In this study we have assessed total of 210 beta- Syphilis does not show any pattern in any study. In our thalassemia major patient registered in Civil Hospital, study we have not assessed malarial infection. Table I&II

41 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 and chart I&II compares the data of both studies. Multitransfused beta-thalassemia major patients are A residual risk of transmitting viral infections during the most susceptible population to acquire transfusion- transfusion of blood products persists despite related infections. Including HepC , owing to regular improvements in donor recruitment, selection, and transfusions of one to three units of blood every three to advances in screening testing. This risk is mainly due to four weeks, which amounts to 12-51 units /year. As the the (1) marker negative window-phase donations, (2) probability of acquiring transfusion-transmitted diseases (TTDs) is related to the probability of being exposed to the immune variant viral strains, (3) persistent antibody- 15 negative (immunosilent) carriers and (4)procedural infected units of blood, which in turn depends on the 13 ,14 prevalence of asymptomatic viremic blood donors in the testing errors. Therefore transfusion-transmitted 16 infections continue to be a serious problem. population and the number of units transfused, hence, the magnitude of risk of TTDs can be appreciated.

TABLE : I PREVALENCE OF HEPATITIS B, HEPATITIS C, HIV AND SYPHILIS IN DONORS IN OUR STUDY

Total Year HepB Reactive HepC Reactive HIV Reactive Syphilis Reactive Sample

Total % Total % Total % Total % 2002 17232 199 1.15 32 0.18 73 0.42 102 0.59 2003 17166 287 1.67 118 0.68 89 0.52 41 0.24 2004 16242 227 1.39 123 0.75 57 0.35 26 0.16 2005 14719 157 1.04 32 0.22 57 0.35 33 0.22 2006 15545 161 1.03 32 0.21 45 0.29 93 0.60 2007 18499 200 1.08 41 0.22 55 0.30 180 0.97 2008 20502 192 0.94 36 0.17 68 0.33 404 1.97 2009 20582 182 0.88 38 0.18 58 0.28 221 1.07 2010 20300 165 0.81 47 0.23 56 0.27 121 0.59 2011 23451 187 0.79 100 0.42 56 0.23 76 0.32 Total 184238 1957 1.06 599 0.32 614 0.33 1297 0.73

CHART : I PREVALENCE OF HEPATITIS B, HEPATITIS C, HIV AND SYPHILIS IN DONORS IN OUR STUDY

42 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 TABLE : II PREVALENCE OF HEPATITIS B, HEPATITIS C, HIV AND SYPHILIS AND MALARIA IN DONORS IN OTHER STUDY

Total Syphilis Malaria Year HepB (%) HepC (%) HIV (%) Sample (%) (%)

2000 1428 1.54 0.28 0.56 0.70 0.00 2001 1864 1.13 0.27 0.64 0.64 0.07 2002 2123 0.89 0.24 0.52 0.42 0.00 2003 2019 1.73 0.19 0.49 0.69 0.04 2004 2118 2.55 0.28 0.52 0.80 0.00 2005 3190 2.63 1.03 0.97 0.82 0.00 2006 3244 1.76 1.02 0.43 0.22 0.00 2007 3625 1.38 1.35 0.55 0.41 0.02 2008 3206 1.56 2.06 0.28 0.62 0.00 2009 4013 1.49 2.19 0.22 0.62 0.05

CHART II PREVALENCE OF HEPATITIS B, HEPATITIS C, HIV AND SYPHILIS AND MALARIA IN DONORS IN OTHER STUDY

In this study (from table III and Chart III) the prevalence of reduce the infection of HepB infection. And all blood units HepC infection is very high in beta-thalassemia major are tested by 4th generation HIV kit, it will test antigen also, patient as compared to other infections like HepB and so reduce the infection rate of HIV. HIV. This may be due to (1)The prevalence of HepC In thalassemics with the age, number of transfusion infection increasing in population (2) Hep B infection is increases. In a study from eastern India, 70 thalassemics detected by testing HbsAg antigen, the window period of and 20 hemophiliacs who received periodic transfusions which is 38.3 days,HIV infection is detected by detecting of packed cells and components,like fresh frozen plasma, p24 antigen and HIV antibody,the window period of which were reported to have an increased prevalence of TTD is 15.0 days , Hep C infectionis detected by testing HCV 17 markers with increasing number of transfusions. In the antibody, the window period of which is 58.3 days which is 18 present study, a positive correlation between the number longest of all. So chances of infection being transmitted of units transfused and the prevalence of reactivity was during window period is more. (3) Hep C is very much observed. infective in initialphase,that is during window period of antibody testing kit, than in the later phase. 18 From table IV and Chart IV we have seen that the prevalence of transfusion transmitted infection is The prevalence of Hep B and HIV infection is low in increasing with age because of increasing number of thalassemia patient as all patients are given HepB transfusions. Reactive cases in Hep C( 07,12,18,25), vaccine to each and every thalassemia patient so it will

43 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 HIV(00,00,01,02) and Hep B(00,00,00,01)in age group CHART : IV (0-3,4-6,7-9,10-12) shows increasing trend with age. we PREVALENCE OF HEPATITIS B, HEPATITIS C AND HIV do not get proper data of more than 12 year age group INFECTION IN DIFFERENT AGE GROUP OF patients because large number of thalassemic patients THALASSEMIA PATIENT drop out from treatment or died due to some complication by that age. A review of the fate of patients followed between 1960 and 1976 at Cornell Medical Center reported a median survival of thalassemia patient was 17.1 years for patients transfused at low haemoglobin level and not chelated, while for hypertransfused and well-chelated patients the median survival is 31 years.20

TABLE: III PREVALENCE OF HEPATITIS B, HEPATITIS C AND HIV IN MULTIPLY TRANSFUSED THALASSEMIA PATIENT

Disease Patients reactive % CONCLUSION Hep B 1 0.47 As hepatitis C is transmitted only by blood and blood products, it is very important to study its prevalence in Hep C 62 29.52 blood donors. About 50% of HCV infection progress to HIV 3 2.85 chronicity so it is more dangerous than other transfusion transmitted infection. As we have seen that the prevalence of HepC infection is increasing gradually it is CHART: III very alarming. It's high incidence in thalassemia patient PREVALENCE OF HEPATITIS B, HEPATITIS C AND HIV should be taken seriously and appropriate steps should be taken. IN MULTIPLY TRANSFUSED THALASSEMIA PATIENT To reduce the incidence of HCV infection donor recruitment, selection, and awareness of donor for risk of HCV infection should be strengthened. It will reduce the prevalence of hep C reactive donor. 4th generation kit in screening test should be use. This will reduce the window period and thereby reduce the prevalence of infection in thalassemia patient.

REFERENCES 1. Choo Q, Kuo G, Weiner A, Overby L, Bradly D, Houghton M. Isolation of a cDNA clone derived from a blood born nonA,nonB viral hepatitis genome. Science 1989, 244:359-62. 2. WHO. Hepatitis C. WHO fact sheet N(0) 164, October 2000b. Available from:URL:URL : 1. ( Cited on 2007 May 14 ). 3. Arpita Chatterjee, Gopeswar Mukherjee Analysis of the trend of hepatitis B, hepatitis C, HIV, Syphilis and malaria infections in a TABLE : IV rural part of West Bengal. Asian Journal of Transfusion Science PREVALENCE OF HEPATITIS B, HEPATITIS C AND HIV july-Dec 2011; vol5 issue 2 :181-182 INFECTION IN DIFFERENT AGE GROUP OF 4. Bonkovsky HI, Metha S. A review and update. J Am AcadDermatol 2001; 44:159-79. THALASSEMIA PATIENT 5. Weathrall DJ, Clegg JB. The thalassemia syndrome. 4th ed. USA: Black well science; 2001. P.80-110. Age group 0 to 3 4 to 6 7 to 9 10 to 12 6. Rund D, Richmilewitz E. Pathophysiology of alpha & beta years years years years thalassemia: Theraputic implication. SeminHematol 2001;38:343- Hep B reactive 00 00 00 01 9. 7. Azarkeivan A, Ahmadi MH, Hajibeigi B, Gharebaghian A, Hep C reactive 07 12 18 25 Shabehpour Z, Maghsoodlu M. Evaluation of transfusion reactions HIV reactive 00 00 01 02 in thalassemic patients referred to the Tehran adult Thalassemia clinic. J ZanjanFac Med 2008;1:35-41.

44 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 8. Goodnough LT. Risk of blood transfusion. AnesthesiolClin North 14. Bush, M.P. (2001) Closing the windows on viral transmission by America 2005; 23:241-52,v. blood transfusion. In: Blood Safety in the New Millennium: AABB 9. Androulla E. Guidelines to clinical management of 2000 Seminar Book (ed. Stramer, S.L. ), 33-54. AABB Press, thalassemia.Nicisia, Cyprus: Thalassemia International Bethesda, Maryland. Federation (TIF) ; 2007. P.36-50. 15. Alter HJ, Stramer SL, Dodd RY. Emerging infectious diseases that 10. Feigin RD, Cherry J, Demmler- Herrison GJ, Kaplan SL. Viral threaten the blood supply. SeminHematol 2007; 44:32-41. hepatitis due to hepatitis A-E and GB viruses. Text book of 16. Ragni MV, Sherman KE, Jordan JA.Viral pathogens. Haemophilia pediatricinfections disease.6th ed. Saunders/Elsevier; 2010; 16 Suppl 5:40-6. 2009.P.1875-6. 17. Moosely JW. Should measures be taken to reduce the risk of 11. Lauer GM, Walker BD. Hepatitis C virus infection. N Engl J Med human parvavirus (B19) infection by transfusion of blood 2003; 345: 41-52 components and clotting factor concentrates? Transfusion 1994; 12. A.J.Zuckerman Viral hepatitis: Transfusion Medicine: vol 18, 34:744-6. Supplement 1 ,April 2008, page 7-19 18. Dr.R.N.Makroo, Transfusion Transmitted Diseases; compendium 13. Kleinman, S.H. & Bush, M.P. (2000) The risks of transfusion of transfusion Medicine, November 2009: page 267-331 transmitted infection : direct estimation and mathematical 19. Rossi's principles of Transfusion Medicine, chapter 46- modelling. In: New Aspects of Blood Transfusion (ed. Contreras, Transfusion-Transmitted Hepatitis:page 718-745 M.), 13, 631-649. BaillereTindall, London. 20. Ehlers KH, Giardina PJ, Lesser ML, et al. Prolonged survival in patients with beta-thalassemia major treated with deferoxamine. J Pediatr 1991; 118:549.

45 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 Screening for Postpartum Depression Dr. Ashish V Gokhale*, Dr. Amit Vaja** *Prof. & Head, **Senior Resident (O&G) Govt.Medical College & Sir Takhtsinghji Hospital, Bhavnagar-2 KEY WORDS : Postpartum Depression, Edinburg's Postnatal Depression Scoring

ABSTRACT A prospective cross sectional Study was conducted at Dep't of Obstetrics & Gynaecology, Govt Medical College & Sir Takhtsinghjihospital Bhavnagar fromAugust 2007 to July 2009. Randomly selected women ( 1 in 10 ) who attented the labour room , got delivered & who attended the OPD clinic at Sir T hospital Bhavnagar were requested to participate in the study and written consent was taken. Randomly selected women were screened for post partum depression using Gujarati version of Edinburgh post natal depression(EPDS) rating scale. Women who do not know Hindi / Gujarati / English were not included in this study. Around 200 patients were screened on the first day postnatal. These 200 women were requested to come back again at 6th post natal day and on 6 th postnatal week for rescreening-108 were screened on 6th day while 62 were screened on 6 th week post natal. For women who could not read Gujarati, the EPDS was read out and the responses were recorded and who could read Gujarati, did self report. EPDS is a 10 item screening instrument specially used for screening post natal depression in various cultures. It has been found to be having high sensitivity, specificity and accuracy. Cut off point 12 was suggested for post natal depression. And at this cut off point depression prevelance was derived amongst the women on 1st post natal day, 6 th post natal day & at 6 th post natal week All women were interviewed using semi structured proforma including demographic data, obstetric data, relationship related data and economical data. A case control study was carried out where depressed individuals were considered as cases and non depressed individuals were considered as controls and risk factors were compared in these two groups to be statistically significant using chi square test and “p value” testing (derived using Epi info software). If the “P value for a particular risk factor found to be less than 0.05 that particular risk factor was said to be statistically significant for developing postpartum depression in our cases. Prevalence of depression was found to 11% at 1st day post partum,7.4% at 6 th day post partum,3.2% at 6 th week post partum. The factors significantly associated with post partum depression were birth of a female child, prim parity, h/o miscarriage, negative feelings during pregnancy, past h/o psychiatric illness. EPDS question were easy to understand by postpartum woman . Further it being easy to apply for the health care personnel it can be used by primary health care workers ( e.g anganwadi worker or multipurpose health worker with proper training.) so that they can apply the score even at the doorstep of the patient at the peripheral(rural) level and large population of post natal women can be screened. So that timely intervention can be instituted and mothers health, child's cognitive and emotional development can be improved

INTRODUCTION Postnatal depression is particularly important because it The World Health Organization (WHO) predicts that is so common and because it occurs at such a critical time depression will be the second greatest cause of in the lives of the mother, her baby and her family. premature death and disability worldwide by the year For every 1,000 live births, 100-150 women will suffer a 2020.1 The suffering caused by depression is profound depressive illness and one or two women will develop a yet often underestimated. It can affect every aspect of a puerperal psychosis.2, Failure to treat either disorder may person's being: their feelings, thoughts and functioning. result in a prolonged, deleterious effect on the relationship

Correspondence Address : Dr. Ashish V Gokhale “Astha”,99/A,Vidyanagar Society, Near SBI,Vidyanagar, BHAVNAGAR-2 [email protected]

46 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 between the mother and baby and on the child's development, maternal suffering or even suicides or poor psychological, social and educational development.3 The marital relationship. There are very few studies carried relationship between the mother and her partner may also out in India to find out the prevalence of post partum deteriorate. depression and they all show grossly varied results (8-22 The morbidity of clinical depression is often prolonged by % based upon different cutt off points and different type of a delay in diagnosis or an inadequate course of treatment. studies & different no. of subjects studied). This may lead The stigma and shame felt by the sufferers who may be to over diagnosis or under diagnosis of the condition. So reluctant to 'confess' their feelings are frequently study conducted to find out the prevalence of post partum important factors in delayed diagnosis. Such reticence is depression and the factors associated with post natal particularly common in postnatal depression, when depression will be fruitful for mother, child and her family's feelings of guilt and failure may be intense. A mother may health. even fear that she will be thought unfit to care for her child. MATERIAL AND METHODS Mental illness is also a significant factor in maternal Study was conducted at Dep't of Obstetrics & mortality. The UK Confidential Enquiry into Maternal Gynaecology,Govt Medical College & Sir Takhtsinghji Deaths (CEMD) reports that psychiatric disorders hospital Bhavnagar from August 2007 to July contributed to 12% of all maternal deaths 2009.Randomly selected women ( 1 in 10 ) who A small body of evidence points to an association registered at Antenatal clinic and those who attented between a mother's depression and the subsequent the labour room as an emergency, got delivered at Sir T report of depression in her partner. Untreated postnatal hospital Bhavnagar were requested to participate in depression is associated with detrimental effects on infant the study and written consent was taken. These women development. The cognitive, emotional, social and were delivered either abdominally or vaginally, delivered behavioral development of the infant all may be affected at full term or a preterm, male or female child may or may both in the long and short term4 . Longer term negative not be having pathology to her or child, of all age group, of influences of mothers' postnatal depression in the first all religion and domicile and from all economical strata of year of life on infants' language skills, social and society thus they were representation the whole emotional development and (particularly in boys) population of our society intelligence quotients, have been demonstrated5 . Women were screened for post partum depression Cognitive development in the children of postnatally using Gujarati version of Edinburgh post natal depressed women is not universally impaired. The effect depression rating scale. Women who do not know appears limited to those children whose mothers find it Hindi / Gujarati / English were not included in this study. difficult to maintain sensitive and active engagement with 200 patients were screened on the first day, 6th post natal the infant6 . day and on 6th postnatal week for rescreening.-108 were th th week Delay in delivering adequate treatment for postnatal screened on 6 day while 62 were screened on 6 post depression or puerperal psychosis is particularly natal. For women who could not read Gujarati, the unfortunate since the response to treatment is good7 . EPDS was read out and the responses were Effective detection and adequate management of these recorded and who could read Gujarati, did self report. disorders requires co-ordination of a wide variety of EPDS is a 10 item screening instrument specially primary and secondary care services, including used for screening post natal depression in various midwives, health visitors, clinical psychologists, cultures. It has been found to be having high community psychiatric services, general practitioners, sensitivity, specificity and accuracy. Each item offers pharmacists, obstetricians and psychiatrists, with other a choice of four responses, ranging from 0 to 3 community agencies, such as voluntary organisations according to severity with the total score ranging 8 from 0 to 30. and social services, providing further support . EPDS assesses rating of Anhedonia and reactivity. (I Post partum depression is a neglected condition in a have been able to laugh and see the funny side of country like India as it does not produce gross symptoms things; I have looked forward with enjoyment to things but that is the reason why the condition may not be ) self blame, anxiety, panic, coping (things have been detected at all or it may be detected very late. Delay or getting on top of me), insomnia (due to unhappiness ) failure to diagnose the condition may lead to detrimental sadness, tearfulness and self harm. effect on the child's cognitive, emotional and intellectual

47 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 Cut off point 12 was suggested for post natal Table 1 shows that the depressed and non-depressed depression. women differed with respect to their age, domicile, For all women risk factors associated with post religion, type of family, monthly income, and status of partum depression based on predictive index for post employment thus the sample was representing the whole natal depression were specifically inquired population. (Development and validation of a predictive index Table 2 pattern of EPDS score for post partum depression – psychological medicine, 1996 ) at 1st post natal day. All women were interviewed Score Patients Patients Patients -N (%) on -N (%) on -N(%) on using semi structured proforma including 1st Post 6th Post 6th Post demographic data, obstetric data, relationship related natal day natal day natal week data and economical data. A case control study was 0-5 158 (79) 90 (83.3) 52 (83.9) carried out where depressed individuals were considered as cases and non depressed individuals were considered 6- 11 20 (10) 10 (9.3) 8 (12.9) as controls and risk factors were compared in these two 12-17 12 (6) 7 (6.5) 2 (3.2) groups to be statistically significant using chi square test 18-23 08 (4) 1(0.9) 0 and “p value” testing (derived using Epi info software). If 24-29 02 (1) 0 0 the “P value for a particular risk factor found to be less then 0.05 that particular risk factor was said to be Table 2 shows that: statistically significant for developing postpartum st depression in our cases. On 1 day post partum out of 200 patients assessed 158(79%) scored between 0-5, 20 (10%) patients scored While assessing the women on EPDS scale study also between 6-11 ,12 (6%) patients scored between 12-17,8 conducted to see any difficulty faced by women during patients (4%) scored between 18-23 and 2(1%) patients answering the questions of EPDS format and for ease of scored between 24-29 on EPDS scale. applying these scale on large sample of women by trained th primary health care workers at periphery level. On 6 day post partum out of 108 patients assessed 90(83.3%) scored between 0-5 ,10 (9.3%) patients OBSERVATIONS & DISCUSSION scored between 6-11 ,7 (6.5%) patients scored between Table 1 Socidemographic characteristic N=200 12-17, 1 patient (0.9%) scored between 18-23 and ,no Characteristic N (%) patients scored between 24-29 on EPDS scale. Age On 6th week post partum out of 62 patients assessed -<20 years 3 (1.5) 52(83.9%) scored between 0-5 ,8 (12.9%) patients -20-24 years 92 (46) scored between 6-11 ,2 (3.2%) patients scored between -25-29 years 76 (38) 12-17,no patients scored between 18-23 or 24-29 on -30-34 years 24 (12) EPDS scale. ->35 years 5 (2.5) Domicile Figure 1 : prevalence of depression -Urban 109 (54.5) -Rural 91 (45.5) Religion -Hindu 138 (69) -Muslim 60 (30) -Others 2 (1) Family -Joint 96 (48) -Nuclear 104 (52) Monthly income -<3000 138 (69) ->3000 62 (31) Employment -Employed 20 (10) -Unemployed 180 (90) n=22 n=8 n=2

48 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 Figure 1- shows the prevelance of depression on EPDS Ghosh Anuradha et al (2011)18 –used EPDS scale for score. At standard cut off score of 12, 22(11 %) women screening of postpartum depression .they found were identified as depressed on EPDS on 1st post natal significant association of depression with poor day,8(7.4 %) on 6th post natal day & 4(3.2 %) on 6 th post socioeconomic group, nuclear family structure, single natal week. mother,and past history of psychiatric illness, history of O' Hara and Swain (1996) did meta- analysis of 59 studies abuse, and poor obstetric outcome.. and estimated that the average prevalence rate of post Table 4 - comparison of demographic characteristic natal depression was 13% TOD (1964) reported a in depressed v/s non depressed women prevalence rate of 2.9% of serious depression during the Characteristic Depressed Non Chi first post partum year while Watson et al (1984) reposted a prevalence rate of post partum depression 22% Thus, N (%) depressed square there is a wide range of the prevalence rate of post partum N=22 N (%) value .8,9. depression found in previous studies N=178 Table 3 : comparison of various studies for the Age prevalence of post partum depression -<20 years 0 3 (1.7) Chi Subjects Post Prevalence Method partum used -20-24 years 11 (50) 81 (45.5) square duration -25-29 years 11 (50) 65 (36.5) 4.98 Paykel et al 120 5-8 weeks 20% CIS (1980) UK -30-34 years 0 24 (13.5) P value Watson et al 128 6 week 12% ICD-9 ->35 years 0 5 (2.8) 0.28 (1984) UK12 months 22% Domicile R.kumar 119 3 months 14% RDC -Urban 14 (63.6) 95 (53.4) Chi and robson 6 months 11% -Rural 8 (36.4) 83 (46.6) square (1984) UK 12 months 6.5% 0.83 O’hara 99 9 weeks 12% CIS P value (1986) Present 200 1st day 11% EPDS 0.36 study 108 6th day 7.4% Religion 62 6th week 3.2% -Hindu 18 (81.8) 118 (66.3) Chi -Muslim 4 (18.2) 59 (33.1) square CIS-clinical interview scale -Others0 1 (0.6) 2.21 ICD-international classification of disease P value RDC-research diagnostic criteria 0.3 EPDS-Edinburgh Postnatal Depression Score. Thus different studies shows wide variation in the Table 4 compares socio demographic characteristic of prevalence of depression according to different methods depressed and non-depressed women. As regards to of assessment used, different duration after delivery at age, domicile, religion, family types the groups were which study conducted , geographic location & no. of comparable. No statistically significant differences were subjects of study10,11 . observed.(as the p value for each risk factor was found to Indian Studies be less than 0.5 so the differences between depressed and non depressed patients for these risk factors were not Vikram patel (2002)17 : 270 mothers recruited during their significant.) 3rd trimester of pregnancy from a district hospital goa.inteview was taken at 34 weeks antenatal,6-8 weeks Earlier, there have been several attempts to identify the and 6 months after childbirth. Depression was found to be characteristics that put women at risk for post partum in 23 % cases at 6-8 weeks and 22 % at 6 months depression but demographic factor have little association 11,12 postpartum with this risk.

49 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 Table 5 comparison of obstetric characteristic in depressed v/s non depressed women

Table 5-shows impact of the gender of new born in subjected to antipathy, criticism and even hostility from causation of post partum depression.it is seen that out of her spouse and extended family, leading her to major 22 depressed individuals 6 (27.3%) delivered a male child depression is more likely to occur. Women who already while rest 16 (72.7%) delivered a female child. And out of had a girl child face greater stress because of social and 178 none depressed individuals 130 (73.1%) delivered a family pressure to give birth to male child and if the child is male child while rest 48 (26.9%) delivered a female child. a girl again the risk of post partum depression is greater. These data gave a p value of 0.00001 (at chi square value Such gender bias and the limited control, a woman and of 18.84) which being less than 0.05% indicated that the over her reproductive health may make pregnancy a birth of a female child was a significant risk factor for stressful experience for her and ultimately lead to post development of post partum depression in this study. partum depression. This response is a reminder that child In this study statistical co – relation between birth of a girl birth is more than a biological event, and that the personal child and post partum depression was found, A similar experience of child birth is deeply embodied in the socio- finding was noted by Vikram et al (2002).17 moral values of the local culture. Culturally, in our male dominated Indian society, male Table 5 compares significance of the history of children are preferred and this male-bias is deeply rooted. miscarriage in causation of post partum depression .It is When a girl child is delivered, the mother may be seen that out of 22 depressed individuals 10 (45.6%) had

50 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 h/o miscarriage while rest 12 (54.4) had no h/o proper training.) so that they can apply the score even at miscarriage. And out of 178 non depressed individuals 25 the doorstep of the patient at the peripheral(rural) level (14.1%) had h/o miscarriage while rest 153 (85.9%) and large population of post natal women can be patients had no h/o miscarriage. These data gave a p screened. So that timely intervention can be instituted and value of 0.001 (at chi square value of 13.38) which being mothers health, child's cognitive and emotional less than 0.05% indicated that h/o miscarriage was a development can be improved significant risk factor for development of post partum depression in this study. REFERENCES 1. Evans J, Heron J, Francomb H, Oke S, Golding J. Cohort study of Figure 2. significance of feeling during pregnancy depressed mood during pregnancy and after childbirth. BMJ 2001; 323:257-60. 2. O'Hara MW, Swain AM. Rates and risk of postnatal depression - a meta-analysis. International Review Psychiatry 1996;8:37-54 3. Forman DN, Videbech P,Hedegaard M, D, Salvig JD, Secher NJ. Postpartum depression: identification of women at risk. Br J Obstet Gynaecol 2000;107:1210-7 4. Warner R, Appleby L, Whitton A, Faragher B. Demographic and obstetric risk factors for postnatal psychiatric morbidity. Br J Psychiatry 1996;168:607-11 5. Grazioli R, Terry DJ. The role of cognitive vulnerability and stress in the prediction of postpartum depressive symptomatology. Br J Clin Psychol 2000; 39:329-47 6. Hendrick V, Altshuler L, Strouse T, Grosser S. Postpartum and nonpostpartum depression: differences in presentation and response to pharmacological treatment. Depression Anxiety 2000;11:66-72 7. Lane A, Keville R, Morris M, Kinsella A, Turner M, Barry S. Postnatal depression and elation among mothers and their n=22 n=178 partners: prevalence and predictors. Br J Psychiatry 1997;171:550-5 Table 5 (figure 2) compares significance of feeling during 8. O'Hara MW. Social support, life events and depression during pregnancy in causation of post partum depression .It is pregnancy and the puerperium. Arch Gen Psychiatry 1986; 43: 569-73 seen that out of 22 depressed individuals 14 (63.6%) used 9. Wickberg B, Hwang CP. Screening for postnatal depression in a to have positive experience while rest 8 (36.4%) had population-based Swedish sample. Acta Psychiatric Scand negative experiences during pregnancy. And out of 178 1997; 95:62-6. non depressed individuals 148 (83.1%) had positive 10. Yoshida K, Marks MN, Kibe N, Kumar R, Nakano H, Tashiro N. experience while rest 30 (16.9%) patients had negative Postnatal depression in Japanese women who have given birth in England. JAffective Disorders1997;43:69-77 experience during pregnancy. These data gave a p value 11. Glasser S, Barell V, Shoham A, Ziv A, Boyko V, Lusky A, Hart S. of 0.02 (at chi square value of 4.84) which being less than Prospective study of postpartum depression in an Israeli cohort: 0.05% indicated that feeling negative during pregnancy prevalence, incidence and demographic risk factors. J was a significant risk factor for the development of post Psychosomatic Obstet Gynaecol 1998;19:155-64 partum depression in this study. 12. Appleby L, Gregoire A, Platz C, Prince M, Kumar R. Screening women for high risk of postnatal depression. J Psychosomatic The differences in depressed V/s. non depressed cases Resources 1994; 38:539-45. for factors like mode of delivery, congenital 13. Beck CT, Gable RK. Further validation of the Postpartum Depression Screening Scale. Nursing journal 2001;50:155-64 malformation/illness to child, associated pathology during 14. Cox JL, Holden JM, Sagovsky R. Detection of postnatal pregnancy, family history of psychiatric illness, feeling depression: development of the 10-item Edinburgh Postnatal tense during pregnancy, feeling depressed during Depression Scale. Br J Psychiatry 1987;150:782-6 pregnancy had no statistical significance. 15. Guedeney N, Fermanian J, Guelfi JD, Kumar R. The Edinburgh Postnatal Depression Scale (EPDS) and the detection of major In the present study no significant association was found depressive disorders in early postpartum: some concerns about between feeling particularly miserable and depressed false negatives. JAffect Disord, 2000; 61:107-12. during pregnancy and an increased risk of post partum 16. Kosinka-Kaczynska K,Horoz E,Wielgos M et al affective disorders in the first week after the delivery;prevalence and risk depression. O' Hara (1995) suggests that depression factors.Ginekol Pol.2008;79:182-5 during pregnancy increases the risk of post partum 17. Vikram patel; Merlyn rodrigues: nandita desouza: Gender, depression by 35 %.8,18. poverty and postnatal depression, a study of mothers in goa, India. The americal journal of psychiatry; Jan 2002 ; 159:43-47 EPDS question were easy to understand by postpartum 18. Ghosh Anuradha,Goswami Sebanti,Evaluation of Postpartum woman. Further it being easy to apply for the health care Depression in a Tertiary care hospital.The J of obstetrics & personnel it can be used by primary health care workers ( gynecology of India sept –oct 2011 61(5):528-530. e.g anganwadi worker or multipurpose health worker with

51 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 Analysis of 63 patients of MDR TB on DOTS plus regimen : An LG hospital, TB Unit, Ahmedabad experience. Dr. Kapadia Vishakha K.*, Dr. Tripathi Sanjay B.** *Assistant Professor, **Professor and head Department of Pulmonary Medicine, AMC MET Medical College, Maninagar, Ahmedabad KEY WORDS : MDR TB, DOTS PLUS, RNTCP

Abstract : Aims : To analyze demographic, clinical, radiological and bacteriological profile, drug sensitivity pattern, adverse drug reactions and treatment outcome in Multi Drug Resistant TB (MDR TB i.e. in vitro resistance to isoniazid and rifampicin) patients treated with DOTS plus regimen. Method and Materials : From August 2007 to June 2012, 63 MDR TB patients were analyzed retrospectively. Sputum smear and culture examination for tubercle bacilli were performed every month in intensive phase started at the end of third month and then every third month in continuation phase until end of treatment. Regular chest radiography was done at commencement of therapy, at the end of intensive phase and at the end of treatment. Analysis was made for following variables: age, gender, extent of lung lesion, correlation of sputum smear and culture conversion with clinical and radiological improvement, drug sensitivity pattern, risk factors for adverse outcome and adverse drug reactions. Results : Nine patients (39.13%) were cured, three patients (13.04%) failed, six patients (26.08%) defaulted and five patients (21.73%) died of total 23 patients whose outcomes are available after 30 months of enrolment. Out of remaining 40 patients four patients defaulted, eight patients died and 28 were still on therapy. Mean time for sputum smear and culture conversion were 4.2±2.1 and 4.29±2.4 months, respectively. Extensive lung lesion, cavitations, poor adherence to treatment, high initial bacterial load and BMI less than 18 are variables associated with poor outcome. Thirty six (57.14%) patients experienced adverse drug reactions and 21 of them required drug modifications. Conclusions : Presence of cavitations, extensive lung lesion, poor adherence to therapy, high initial bacillary load and low BMI are associated with unfavourable outcomes. Sputum smear and culture conversion at the end of third and fourth month are not indicators to predict outcome. Sputum smear and culture conversion are very well correlated with clinical and radiological improvement.

INTRODUCTION pulmonary TB cases in India is 64000 (range, 44000 to The emergence of drug resistant mycobacteria has 84000) annually. Treatment of MDR TB is challenging due become a significant public health problem world over to toxicity of second line drugs. In present study we creating an obstacle to effective TB control. Confirmed analyzed different factors affecting conversion of sputum Multi Drug Resistant tuberculosis (MDR TB) case is smear and culture (Patients will be considered sputum defined as an MDR-TB suspect who is sputum culture smear/ culture converted after having two consecutive positive and whose TB is due to Mycobacterium negative results taken at least one month apart), clinical tuberculosis that are resistant in-vitro to at least isoniazid and radiological improvement and their correlation. (H) and rifampicin (R). (The culture and Drug Sensitivity SUBJECTS AND METHODS Test results are being done from an RNTCP accredited Data collection : laboratory). As per the WHO global TB report 2011, estimated number of MDR TB cases out of notified Data of 294 patients of MDR suspect (CAT I failure, CAT II sputum smear positive after four month or later and

Correspondence Address : Dr Kapadia Vishakha K. 9, Jivanchhaya Society, Near Radhaswami Satsang, Ranip, Ahmedabad - 382480. E-mail : [email protected]

52 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 sputum positive contacts of MDR TB) were obtained from evaluation. Thyroid, hepatic, renal function tests and medical records like treatment card and registers from complete blood counts were done. HIV testing by enzyme August 2007 to June 2012. linked immunosorbent assay done after pre test Guidelines for MDR TB suspect case were revised in May counselling and informed consent. All patients were 2012 which includes: referred to DOTS plus site where DOTS plus treatment were started after evaluation. – CriteriaA‐ All failures of new TB cases (on CAT I), sputum smear positive re‐ treatment DOTS plus regimen : cases who remain smear positive at four As per RNTCP guidelines this regimen includes six drugs month or later (on CAT II), All Pulmonary kanamycin (Km), ethambutol (E), pyrazinamide (Z), TB cases who are contacts of known cycloserine (Cyc), ethionamide (Eto) and MDR TB case ofloxacin(ofx)/levofloxacin (Lfx). These drugs to be taken – Criteria B‐‐ All Re treatment smear positive at daily except Km which is to be taken six days per week. diagnosis & any smear positive follow up Intensive phase includes all six drugs and continued for of new or retreatment cases six to nine months while continuation phase includes four – Criteria C‐ Retreatment smear negative cases at drugs (Cyc, Eto, E, Ofx/Lfx) taken for 18 months. PAS diagnosis, HIV TB co‐ infected cases in (Para amino salisylic acid) is reserved drug for patients addition to the suspects in Criteria B. who develops adverse drug reaction or who conceives while on therapy (who cannot be given Kanamycin or History was obtained from patients, health workers, STS, Ethionamide). STLS, DOT provider etc... Of these MDR suspects patients 230 sputum samples sent for culture and Patient monitoring : sensitivity testing and out of them 147 patients (63.91%) Patients were regularly assessed for clinical and were turned out to be DR TB cases which are resistant to radiological improvement. Weight done every month, mono rifampicin resistant (n=42) or isoniazid plus chest radiography was done six monthly and frequent rifampicin resistant (n=105). As per RNTCP guidelines assessments done for adverse events. Sputum smear mono rifampicin resistant cases are also included for and culture were done at the end of 3, 4, 5, 6, 7 month and DOTS plus treatment. Hence out of total 147 patients, 63 then every 3rd month in continuation phase. Renal function patients were put on DOTS plus regimen. 36 patients test was done every month in intensive phase and then refused, 32 patients migrated, and 16 patients died of every 6th month in continuation phase. remaining 84 patients. Non MDR TB patients were Outcome definitions : continued on CAT II regimen. The details of demographic data, chemotherapy, adverse drug reactions to drugs, Cure: An MDR-TB patient who has completed treatment regularity of treatment, follow up assessment as well as and has been consistently culture negative (with at least 5 regular sputum bacteriology and chest radiography consecutive negative results in the last 12 to 15 months). results were recorded. If one follow-up positive culture is reported during the last three quarters, patient will still be considered cured Sputum bacteriology and other investigations: provided this positive culture is followed by at least 3 Sputa were collected in sterile Mc cartney bottles consecutive negative cultures, taken at least 30 days containing cetyl pyridinium chloride (CPC) or falcon apart, provided that there is clinical evidence of tubes. All specimens were subjected to culture for improvement. mycobacterium tuberculosis and drug susceptibility Death : An MDR-TB patient who dies for any reason testing for isoniazide (H), rifampicin (R), ethambutol (E) during the course of MDR-TB treatment and streptomycin (S) on Lowenstein Jensen (LJ) medium which were sent in CPC bottle. Specimen collected in Treatment failure: Treatment will be considered to have falcon tubes were subjected to Line Probe Assay (LPA) to failed if two or more of the five cultures recorded in the know sensitivity of H and R only. Sputum culture and drug final 12-15 months are positive, or if any of the final three sensitivity results are available after three to four months cultures are positive. in LJ media while LPA is a rapid diagnostic test which Treatment default: An MDR-TB patient whose MDR-TB gives result within few days. Because of this fact RNTCP treatment was interrupted for two or more consecutive has adopted LPA method for diagnosis of MDR TB cases months for any reasons. after August 2009. However LPAis not useful for follow up sputum cultures hence follow up cultures are being done Data was compiled and analyzed for different parameters by LJ media. like age, gender, socio economic status, co morbid conditions, reason for MDR suspect, method of Prior to starting treatment all patients underwent detailed diagnosis, drug sensitivity to first line anti tuberculosis clinical, serological, bacteriological, radiological drugs, adverse drug reactions, sputum smear and culture 53 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 conversion, weight gain, radiological improvement. We were diagnosed by Line Probe Assay of which 37 also analyzed correlation of sputum smear and culture (90.24%) were HR resistant and five (9.76%) were mono conversion with weight gain and radiological R resistant. improvement. Adherence to therapy : RESULTS Forty nine (77.78%) patients were regular in therapy. Demographic and clinical profile : Fourteen patients (22.22%) had poor adherence to Sixty three patients were put on category IV regimen after therapy, which was defined as missing more than 20% of diagnosis of MDR TB. Mean age was 34±11.54 years the designated number of doses. (range, 16 to 62 years). Forty (63.49%) patients were Outcome : male and 23 (36.51%) were female. Mean body weight Total 38 (60.32%) patients had completed intensive was 41.80±10.82 kg (range, 20 to 60 kg). Mean body phase, of which six (15.78%) had taken IP for six months, mass index (BMI) was 18.67±3.45 (range, 14 to 23.5). 13 (34.21%) for seven months, eight (21.05%) for eight Concomitant medical diseases were present in 23 months and 11 (28.95%) for nine months. Total 12 patients (36.5%). These included hypertension, COPD, patients had completed full course of treatment of which hyperlipidemia, chronic alcoholic liver disease. Six nine were declared cured and three were declared as (9.51%) patients were immunocompromised, of which failure. All patients who failed therapy were suspected as two (3.17%) were HIV positive and four (6.34%) were XDR TB (resistance to at least Rifampicin and isoniazid, diabetic. Both HIV positive patients were already known in addition to any fluoroquinolone, and to at least one of cases and on anti retroviral therapy. In present study no the three following injectable drugs used in anti TB patient was having thyroid abnormality before initiation of treatment: Capreomycin, Kanamycin and Amikacin) and treatment. There was not any female with pregnancy second line drug sensitivity were sent which revealed non before or after initiation of therapy. XDR TB (sensitive to ofloxacin) in two patients and Drug sensitivity pattern: remaining one patient was turned out to be an XDR TB Fifty three (84.12%) patients were of Category II (two) case and died afterwards. Total ten patients had defaulted failure, eight (12.69%) patients were of Category I or III therapy due to social reason (20%), migration to other failure, one (1.58%) patient was contact of MDR TB case state or territory (50%) and adverse drug reaction (30%). and one (1.58%) patient had taken treatment from private Amongst defaulter six patients had defaulted before sector. MDR TB was diagnosed by LJ culture initially. completion of intensive phase. Three patients had history Newer diagnostic method Line Probe Assay (LPA) was of defaultation in previous therapy also. adopted by RNTCP after August 2009. Twenty one Of the variables that might be associated with the adverse (33.33%) patients were diagnosed by LJ culture, of which treatment outcome is presence of cavitations, BMI< 18, 12 (57%) were SHER resistant, four (19.04%) were SHR extensive lung lesion, poor adherence to therapy and resistant, two (3.17%) were HER resistant and three initial high bacterial load (TableI). (14.28%) were HR resistant. Forty two (66.66%) patients Table I Demographic, clinical, bacteriologic and treatment characteristics in 23 MDR TB patients with different outcome Treatment outcome Variables P Value Success (n=9) Failure/death/ default (n=14) Age 35.44 (mean) 35.05 (mean) NS Male sex 6 (66.66%) 9 (64.28%) NS Presence of cavity 3 (33.33%) 10 (71.42%) <0.05 Extensive disease 3 (33.33%) 9 (64.28%) <0.05 Initial bacterial load 3+ n=0 3+ n=5 <0.05 2+ n=4 2+ n=4 NS 1+/Scanty bacilli n=5 1+/ Scanty bacilli n= 5 NS Poor adherence 0 6 (42.85%) 0.0001(HS) HIV positivity 0 1 (7.14%) NS Diabetes 0 1 (7.14%) NS Adverse events which needed drug 3 (33.33%) 5(35.71%) NS modifications BMI ≤ 18 3 (33.33%) 10(71.42%) <0.05 NS= not significant, HS= highly significant 54 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 Out of 63 patients 15 patients had not completed radiography, three (21.42%) had neither sputum smear treatment up to three months, so follow up sputum smear nor culture conversion throughout therapy they had examination, sputum culture, chest x- rays and weight completed, one (7.14%) patient was diabetic. Five available for only 48 patients. From these 48 patients 32 (35.71%) patients developed adverse drug reaction (66.66%) and 27 (57.25%) had conversion of sputum which required modifying treatment, of these one patient smear and culture respectively at end of 3rd month. Eight developed severe jaundice, altered behaviour and joint (16.66%) patients had neither smears nor culture pain. One patient had carcinoma glottis and two had conversion throughout therapy they had completed. chronic obstructive pulmonary disease. Two (14.28%) Remaining eight patients had conversion of sputum patients were SHER resistant, nine (64.28%) were HR smear and culture from the end of 4th month to 12 th month. resistant, one (7.14%) was SHR resistant and two Thirty (62.5%) patients showed radiological (14.28%) were mono R resistant. improvement, 15 (31.25%) showed static lesion and only Adverse drug reactions : 3 (6.25%) showed radiological deterioration during treatment. Thirty five (72.91%) patients had weight gain, Of 63 patients, 36 (57.14%) had adverse drug reactions of 10 (20.83%) had weight loss and 3 (6.25%) had no varying severity. The most common ones were related to change in weight during or at end of treatment. Sputum gastrointestinal system and central nervous system. smear and culture conversion were well correlated with Modification of drug regimen required in 21 patients. Eight radiological improvement and weight gain. of them required to terminate cycloserine treatment after a mean of 4.1± 3.2 months (range, 1 to 9 months) During treatment 16 patients who were converted because of depression (n=2), altered behaviour (n=1), negative for sputum smear and culture were again suicidal attempt (n=1), insomnia (n=2) and seizure (n=1). became positive. Of which eight patients were persistent Four patients required termination of aminoglycosides positive till therapy continued. Out of these eight patients after a mean of 2.5± 2.1 months (range 1 to 6 months) second line drug sensitivity were available for three because of nephrotoxicity or otovestibular toxicity. Four patients who showed that one patient was XDR TB case patients had severe joint pain and so needed to and remaining two were non XDR TB case, three patients discontinue pyrazinamide. Two patients developed expired and two were defaulter. Remaining eight patients blurring of vision and so ehambutol was withdrawn from become positive for short period of time after initial therapy. One patient had hypothyroidism after conversion. commencement of therapy and ehionamide was Analysis of expired cases : discontinued. Hypersensitivity was observed in one patient who required stopping ofloxacin. Various adverse Study revealed that among total 14 expired patients, drug reactions observed during therapy are depicted in 11 (78.57%) had far advanced lung lesion on chest table II. Table II Adverse drug reactions observed System Manifestations No of patients (%) Actions taken for ADR Gastro Nausea, vomiting, 14(22.22%) Symptomatic treatment intestinal epigastric discomfort Central Insomnia, depression, 8 (12.69%) Cycloserine stopped in all patients nervous seizure, suicidal attempt Skeletal Joint pain 5 (7.94%) Symptomatic treatment (n=1) Pyrazinamide stopped, para amino salicylic acid added (n=4) Otovestibular Giddiness, tinnitus, 3 (4.76%) Kanamycin stopped and PAS added (n=3) impaired hearing and kanamycin alternate day (n=1) Ophthalmic Visual blurring 2 (3.17%) Ethambutol stopped Endocrinal Hypothyroidism 1(1.58%) Ethionamide stopped and pyrazinamide added Renal Renal function impairment 1 (1.58%) Kanamycin stopped and PAS added Dermatologic Hypersensitivity, rashes 1(1.58%) Ofloxacin omitted permanently Hepatobiliary Jaundice 1(1.58%) Pyrazinamide and ethionamide stopped temporarily

55 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 DISCUSSION for all patients with MDR TB5 . BMI less than 18 is also In our study younger population with lower weight patients associated with poor outcome, which is comparable to are more affected in contrast to other studies1-3 , while one study (unpublished data, DOTS plus pilot project, Gujarat). Similar results were observed in one another other demographic profile and clinical characteristics 6 were similar to other studies, with male patients' study also . predominance. Second line anti tubercular treatment adverse events Among the variables that were found to be independently leading to treatment interruption or defaultation was associated with adverse outcome of patients, the observed in present study. Most common adverse event presence of cavitations might affect drug penetration and was related to gastro intestinal which is also seen in other 7, 8 thus decrease the efficacy of anti tubercular drugs. It was studies .though severe adverse reactions were found that cavitary lesion per se, irrespective of drug frequent, treatment could be continued in most cases with sensitivity pattern was associated with poor treatment modifications of the treatment regimen. Other studies outcome4 . Irregularity of treatment linked with adverse have reported major adverse reactions ranging from 19- 7-10 outcome is not unexpected and emphasizes that 72% . Central nervous system related adverse events importance of directly observed therapy in the were second most common which lead to omission of management of tuberculosis, which should be mandatory cycloserin in our study. Table III Adverse Drug Reactions (ADR) in different studies ADR (system involved) Wai Yew W. et al11 Thomas A. et al10 Torun T. et al9 Present study (%) (%) (%) (%) Gastro intestinal 20 67 14 22.22% Central nervous 17.46 8 31.2 12.69% Skeletal 7.93 - 11.4 7.94% Otovestibular 14.28 13 41.8 4.76% Ophthalmic 3.17 - - 3.17% Endocrinal - - - 1.58% Renal 3.17 - - 1.58% Dermatologic 1.58 18 4.5 1.58% Hepatobiliary 1.58 4 4.5 1.58% In this cohort study of MDR TB patients, those who research centre, where only 36% cure rate was responded achieved sputum culture negativity during observed10 . Similarly studies from Argentina, Peru and early months of therapy, usually within four months. This USA have reported positive treatment outcome of around concurs with a study of HIV negative subjects with MDR 45%1, 12, 13 . The unfavourable outcome shown in these TB. In our study sputum culture conversion at three to four series was strongly associated with greater number of month was not predictive of eventual cure, which was drugs received previously and male sex and resistance to shown in other series11 . more than five drugs. A report from India had shown 68% 14 The poor cure rate (39.13%) was observed in the current cure rate . On the contrary to our study other reports from study, is similar to another report from tuberculosis Vietnam, Korea, Netherland and Turkey had shown cure rate of above 75%3, 15-17 . Table IV Outcome of MDR TB treatment in different studies Thomas A. Single R Van Deun A. Johnston JC Present Outcome 10 7 18 6 et al et al et al et al study Cure (%) 37 61 69 62 39.13 Default (%) 24 18 12 13 26.08 Death (%) 13 19 14 11 21.73 Failure (%) 26 3 5 - 13.04 Transfer out (%) - - - 2 -

56 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 In present study poor cure rate was observed mainly due 11. Wai yew W., Kuen Chan C, Hung Chau C, Cheuk Ming Tam C et al. to high default (26.08%, mainly due to migration and Outcomes of Patients With Multidrug-Resistant Pulmonary Tuberculosis Treated With Ofloxacin/ Levofloxacin-Containing adverse rug reactions) and death rate (21.73%, mainly Regimens. Chest 2000;117;744-751 due to extensive lung lesion and low BMI) in spite of high 12. Palmero DJ, Ambroggi M, Brea A et al. Treatment and follow up of sputum culture conversion rate (74.50%) at the end of HIV negative multi-drug resistant tuberculosis patients in an intensive phase treatment. infectious diseases referral hospital, Buenos Aires, Argentina. Int J Tuberc Lung Dis, 2004, 8: 779-784. In summary, this study describes meta-analysis of 13. Suaraz PG, Floyd K, Portocarrero J et al. Feasibility and cost patients on DOTS plus regimen. Migration, alcoholism, effectiveness of standardised second line drug treatment for drug toxicity are important factors leading to defaultation chronic tuberculosis patients: A national cohort study in Peru. or poor treatment adherence and ultimately low cure rate Lancet 2002; 359: 1980-1989 in MDR TB treatment. If patient takes drug regularly then 14. VKArora, R Sarin, R Singla et al. DOTS-Plus for patients with multi- failure rate of this treatment is not much high. drug resistant tuberculosis in India: Early results after three years. Indian J Chest DisAllied Sci 2007; 49: 75-79 Emergence and spread of MDR TB can threaten the 15. International organization for migration tuberculosis working global TB control. The treatment of MDR TB is prolonged, group. Outcome of second line tuberculosis treatment in migrants expensive and often unsuccessful. Hence prevention of from Vietnam. Tropical Medicine and International Health 1998; 3: MDR TB is more important rather than treatment. 975-980. Strengthening the program by intensely evaluating 16. Geerligs WA, Van Altina R, De Lange WCM, Van Soolingen D, treatment regimens, assuring treatment adherence, Vander Der werf TS. Multi-drug resistant tuberculosis: Long term treatment outcome in the Netherlands. Int J Tuberc Lung Dis 2000; supporting true DOTS, aggressive and proactive 4: 758-764. management of adverse events and infection control are 17. Tahaoglu K, Torun T, Sevim T et al. The treatment of multidrug very essential. resistant tuberculosis in Turkey. New England Journal of Medicine 2001; 345: 170-174. REFERENCES 18. Van Deun A, Salim MA, Das AP, Bastian I, Portaels F.Rresult of a 1. Goble M, Iseman MD, Madsen LA, et al. Treatment of 171 patients standardised regimen for multidrug-resistant tuberculosis in with pulmonary tuberculosis resistant to isoniazid and rifampin. N Bangladesh. Int J Tuberc Lung Dis. 2004 May;8(5):560-7. Engl J Med 1993; 328:527–532 2. Park MM, Davis AL, Schluger NW, et al. Outcome of MDR-TB patients, 1983–1993: prolonged survival with appropriate therapy. Am J Respir Crit Care Med 1996; 153: 317–324 3. Park SK, Kim CT, Song SD. Outcome of chemotherapy in 107 patients with pulmonary tuberculosis resistant to isoniazid and rifampin. Int J Tuberc Lung Dis 1998; 2:877–884 4. Kritski AL, Rodrigues de Jesus LS, Andrade MK, et al. Retreatment tuberculosis cases: factors associated with drug resistance and adverse outcomes. Chest 1997; 111:1162–1167 5. Fujiwara PI, Sherman LF. Multidrug-resistant tuberculosis: many paths, same truth. Int J Tuberc Lung Dis 1997; 1:297–298 6. Johnston JC, Shahidi NC, Sadatsafavi M, Fitzgerald JM. Treatment outcomes of multidrug-resistant tuberculosis: a systematic review and meta-analysis. PLoS One. 2009 Sep 9;4(9):e6914. doi: 10.1371/journal.pone.0006914. 7. Singla R, Sarin R, Khalid UK, Mathuria K, Singla N, Jaiswal A, Puri MM, Visalakshi P,Behera D. Seven-year DOTS-Plus pilot experience in India: results, constraints and issues. Int J Tuberc Lung Dis. 2009 Aug;13(8):976- 81. 8. Malla P, Kanitz EE, Akhtar M, Falzon D, Feldmann K,8. Gunneberg C et al. Ambulatory-based standardized therapy for multidrug resistant tuberculosis: experience from Nepal, 2005-2006. PLoS One 2009; 4:08313 9. Törün T, Güngör G, Ozmen I,Bölükbaşi Y , Maden E, Biçakçi B, Ataç G, Sevim T,Tahaoğlu K . Side effects associated with the treatment of multidrug-resistant tuberculosis. Int J Tuberc Lung Dis. 2005 Dec;9(12):1373-7. 10. Thomas A, Ramchandra R, Rehaman F, Jaggarajamma K, Santha T, Selvakumar N, et al. Management of multi-drug resistant tuberculosis in the field- Tuberculosis Research Centre experience. Indian J Tuberc 2007: 54: 117-124

57 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 Trends of Suicidal Poisoning Deaths in Females of Ahmedabad (Gujarat Region) Dr. Prajapati KB*, Dr. Satani Dipali**, Dr. Prajapati TB*, Dr. Merchant SP*** *Assistant Professor, ***Professor & Head, Department of Forensic medicine & Toxicology AMC MET Medical College **Associate Professor, Department of Ophthalmology, Nagari Hospital, Ahmedabad, Gujarat, India. KEY WORDS : Suicidal deaths, Autopsy, Poisoning.

ABSTRACT Background : Pattern of suicidal deaths is a reflection of the prevailing social set up and mental health status of the region. Many cultural and socio-economic factors of a country are responsible for the causation of such deaths in females. Suicidal deaths happen almost everywhere in the world. Objective : The current study was conducted with an objective to understand the magnitude and pattern of suicidal poisoning deaths in female. And to know the various reasons associated with them. Methodology : A two year retrospective studyfrom May 2007 to April 2009 was conducted at the Department of Forensic Medicine & Toxicology inSmt. NHL Municipal Medical College,Ahmedabad. During this period, a total 45 female cases out of 130 of suicidal poisoning related deaths were autopsied conducted in the mortuary of Smt. NHL Municipal Medical College, V. S Hospital campus atAhmedabad. Results : Study revealed that second most of the victims of fatal poisoning were Hindus, married Females of middle socio-economic status who died due to self ingestion of some poison Preference for organophosphates. Suicidal poisoning was commonly encountered during afternoon hours in females. Conclusions : The result of this study indicates that, by not only a strong legal support network but also opportunities for economic independency, essential education and awareness, alternative accommodation and a change in attitude and mindset of society, judiciary, legislature, executive, men and the most importantly woman herself can lower or prevents the such suicidal deaths.

INTRODUCTION as per 2011 census in an area of 22,473 sq kms. The Suicidal death is one type of violent death which is caused postmortem center at our hospital is under the by a deliberate act of the decedent with the intent to kill department of forensic medicine and caters the need of him. Data on such suicidal deaths in a particular our City and surrounding rural areas. All the poisoning geographic area can give the reflection of social and deaths coming for the postmortem examination to this mental status of females. Suicidal deaths of married center are studied, the study being retrospective from women have been an increasing trend in Indian society May 2007 toApril 2009. during the recent past years. The materials comprised 45 autopsy cases of suicidal The most obvious reason behind such deaths is unending Poisoning deaths of females of all ages, out of total 130 demands of dowry (Cash / Kinds) by their husbands and / autopsies of suicidal poisoning done in our mortuary. The or in laws, for which they torture the bride in such a way cases included not only Ahmedabad city but also from that she commits suicide, either by burning, poisoning, surrounding areas of Ahmedabad region. These 45 hanging, jumping from terrace or by some other means. autopsy cases of suicidal deaths had taken as study Besides this, family quarrels due to ill-treatment by In- population irrespective of race, religion and caste after laws, rash and negligent behavior or extra-marital affairs taking detailed informed written consent from next to kin of husband and mal-adjustment and infertility in wives are of the deceased. Information regarding the name, age, other reasons behind such deaths. Its increasing address, occupation, education, socio-economic stat incidence is symbolic of continuing erosion and marital status, history of death, apparent motive and the devaluation of women's status in independent by this circumstances leading to such deaths of deceased were study, we can know the various causes of suicidal deaths collected from the relatives / friends of the deceased, in females and the various motives behind them. hospital records and the concerned investigating agencies. Other information like cause of death from the MATERIALS AND METHODS autopsy reports and final cause of death formed from the Ahmedabad is a district with population of about 56 lacks reports of samples and viscera, subjected to chemical

Correspondence Address : Dr. K. B. Prajapati Forensic medicine & Toxicology AMC MET Medical College, L.G. Hospital, Ahmedabad.

58 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 analysis, histopathological examination and other urban and rural area at chemist shop as well as at number investigations. Proforma for study was prepared and all of provision stores (14, 15, 20) collected data were put into the master-chart, which was DISCUSSION prepared and then feed into the computer in Excel worksheet and then analyzed. Cases of suicidal, poisoning by various chemical compounds is being reported by very frequently from all OBSERVATION parts of India and other countries. With increasing use of The present study comprised 45 (28.89%) autopsy cases chemicals in industries, agriculture and domestic of suicidal deaths of females out of total 130 autopsies of practices, incidence of poisoning are also increasing and suicidal poisoning. Maximum cases (44.44%) were seen a steady incline has been reported not only in developed in age group of 14 – 23 years followed by 24.44% and countries but also in developing countries like India, Sri- 15.55 % cases in age group of 34–43 and 24–33 years Lanka, Philippines, and Pakistan(16) Comparison between respectively. Minimum cases (04.44%) were seen in different studies on cases of poisoning brought for post- fifth/sixth decade (54-63) while no case recorded in child partum is difficult because pattern of poisoning is different below 10 years. There were more cases seen in urban in various regions. In our study 34.61 % of cases region (55.55%) than rural (44.44%). (Females) brought for autopsy were in relation to Housewives constituted the largest single category poisoning. amounting nearly 77.78% and after that laborers Banarjee[12] who studied the vulnerability of Indian (08.88%) and students (06.66%) were involved. Only 3 women. They found that the incidence of suicide was cases was seen in employed women 43/100,000 in Bengal and that women (79.3%) Most of females were literate (66.66%) who become outnumbered men. 75% of the victims were below 25 victims in such deaths in which 22.23% studied up to years of age and the commonest cause for suicide in primary education, 26.66% up to secondary school, women was quarrel with husband, while in men it was with 17.77% up to higher secondary graduation. Rest victims parents. Ingestion of insecticide was the most common were illiterate (33.34%). method of committing suicide. Highest numbers of cases (48.88%) were seen in class II The incidence of poisoning is maximum in 2nd and 3rd (Middle) followed by 37.77% and 13.34% cases in class III decade of life which is similar to the study of KSN Reddy, (17,18,19) (Lower) and class I (upper) respectively. Gannarda and study of Vinay Shetty, P.R. Shukla. Sharma BR et al (2004)78 , Mohan Kumar T et al (2006) , Hindus (62.22%) comprised the single largest category Sharma BR et al (2007)910 , Srivastava AK et al (2007) , followed by Muslims (31.11%). Only 02 (04.45%) cases Geeta S et al (2008)11 , Singh AK et al (2009) 12 and Kailash were belonging to the Christian. UZ et al (2009)13 In a study of Vinay Shetty 52.25% of Out of total number of cases, more than half of victims cases of 2nd and 3rd decade of victim.(18). It again might be were married (68.89%) while 31.11% were unmarried. due to reason that this group is more involved in all types In the total 45 suicidal cases, most common motive for of strain, i.e. domestic, educational and un-employment. suicidal deaths was mental stress due to unknown Thus, it definitely requires a higher emphasis before it reasons (71.11%) followed by family quarrel (08.88%), may affect the entire nation's economy. chronic illness (04.45%), Financial problem Cruelty by There were more cases seen in urban region (45.38%) husband & in-law( 04.45%), Dowry (04.45%), Failure in than rural (20.0%). This finding was consistent with the love (02.22%), mal-adjustment in marriage life (02.22%), findings of Sharma BR et al (2004)7 . In the study of and. In some cases there was more than one motive for authors6, 11, 13 most cases were from rural region, which suicide. was totally in disagreement with those of, present study. In about all poisoning route of administration of poisoning Housewives constituted the largest single category was oral. Majority of poisoning cases, 38 above to get amounting nearly 77.78%. This finding was consistent hospitalized for various duration before death where as 2, 4,10,11,13 with the findings of others and Statistics of NCBI remaining are 7 could not be hospitalized due to various 15 2008 . Majority of victims were housewives that were reasons. The poisoning death could be related to dose dependant on their husbands or in-laws. ingested as well as the time elapsed between ingestion and arrival at hospital. Carbamate propoxur and Most of females were literate (89.13%) who become aluminum phosphide compared were most commonly victims in such deaths in which 30.44 % studied up to used for suicidal poisoning because Baygon is easily secondary school, 25.36% up to higher secondary, available and relatively cheap compound. Aluminum 25.36% up to graduation and only 7.97% were primary phosphide is again easily available and fatal dose education. Rest victims were illiterate (10.87%). This required is too small. Both compounds are available in finding was consistent with the findings of Kailash UZ et al

59 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 (2009)13 in which 72.35% of cases were educated less Hindu and 0.14% was Christians, which was slightly in than metric and 12% were illiterates. disagreement with those of, present study. Reason This finding was inconsistent with the Statistics of NCBI behind such finding, Bangladesh was Islamic country. 200815 in which the maximum number of suicide victims Out of total number of cases, more than half of victims was educated up to Primary level (25.3%). Illiterate and were married (69.57%) while 25.36% were unmarried and Middle educated persons accounted for 20.7% suicide 5.07% were widow. This finding was consistent with the victims and 23.7% respectively. Only 2.6% suicide victims findings of authors 6,11,13,15 were graduates and post-graduates. In the total 138 suicidal cases, most common motive for This change may be because of change in life style, socio- suicidal deaths was mental stress due to unknown economic conditions and population affected in the region reasons (51.45%) followed by family quarrel (10.87%), of South Gujarat. For the fact, that the mostly affected mental illness (10.15%), chronic illness (7.97%), failure in were immigrants from neighboring states and belonged to love (7.25%), mal-adjustment in marriage life (6.52%). lower socioeconomic strata and were from major Srivastava AK (2007)10 in their study had however constituent of laborer class, low literacy rate could have showed that Ill-treatment by the in-laws, excessive been evident. Authors4, 6, 10, 11 , in their study had however pressure for dowry and negligent behaviour of husband showed that illiterate women were most vulnerable, which were the main reasons behind suicidal deaths, which was was totally disagreement with those of, present study. slightly in disagreement with those of, present study. According to Kulshrestha P et al (2001)4 about half of According to Geeta S (2008)11 , marital disharmony was victims were found to be illiterate and among those who the principal reason behind suicide. According to Singh literate, non-matriculates formed more than half of the AK (2009)12 , depression, insecurity and excess work load graduate and technical/professional combined responsible for the high incidence of suicidal deaths. constituted merely 9.39% of total. According to Kailash UZ et al (2009)13, dowry was the Highest numbers of cases (40.58%) were seen in class II most common motive for suicidal deaths. According to (upper - middle) followed by 36.96% and 13.04 % cases in Statistics of NCBI 200815, Family Problems and Illness, class III (middle) and class IV (lower-middle) respectively. accounted for 23.8% and 21.9% respectively, were the Only 3 cases were present in class V (lower) while class I major causes of suicides among the specified causes. (upper) was also involved in 12 cases. This finding was Love Affairs (3.0%), Bankruptcy, Dowry Dispute and not consistent with the findings of Srivastava AK et al Poverty (2.4% each) were the other causes driving people (2007)10 which shown majority of the victims were towards suicides. belonging to class III (middle) or class IV (lower-middle) Self-poisoning is one of the oldest methods tried for socio-economic groups. committing or attempting suicide, only the substances is Kulshrestha Pet (2001)413 and Kailash UZ (2009) in their used for poisoning change from time to time and place to study had however showed that class IV (lower – middle) place. Increasing stress and strains in life and diminished socioeconomic class was most vulnerable while in the mental strength to cope up with this stress may be the study of Mohanty MK (2004)67 , Sharma BR (2007) and reason behind this; other reasons may be free and easy Geeta S (2008)11 , class V (lower) socio-economic class availability, social problems like marital disharmony, were mostly involved, which was in disagreement with economic hardship, disagreement, scolding, un- those of, present study. The reason for the above said employment, adjustment problem, quarrel with other (21) findings may be due to economic instability leading to members etc. violence against women in the form of dowry deaths Carbamate-Propoxure and Aluminum phosphide Hindus (89.86%) comprised the single largest category poisoning deaths are commonest because of being followed by Muslims (9.42%). Only 1 case was belonging cheap, easily available without any restriction in market to the Christian. This finding was consistent with the as Baygone Spray for Carbamate-Propoxure and findings of authors2, 4, 6,10,11,13 . We believed that marital / Celphos, Alphos, Quickphos, Phostoxin, Phosphotex etc. family discards and dowry problems were less in Muslim for Aluminum Phosphide, highly efficacious and non- (8,9,10) due to simple rituals and practice of "Mahr" / "dower" availability of specific antidote . instead of evil practice of "dowry". Very low population In all cases of deaths due to poisoning show cyanosis and and higher and professional qualification and cultural presence of froth at mouth and nostrils as prominent differences may be responsible for only 1 case having features. Whenever these finding are present poisoning been reported from Christian religion. Rahim M et al should be rule out first. When we find congestion of 3 (1996) in their study had however showed that 95.47% of internal organs with cyanosis and froth chances of the unnatural deaths were the Muslims, 4.25% were detecting poison are more. In our study out of 11(24.44%)

60 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 cases shows the presence of froth at nostrils, 24(53.33%) health information and forms the cornerstone of the health cases shows presence of cyanosis and internal information system. At provincial level it is needed for examination liver, kidney congested in all cases. In study health planning and deciding on intervention strategies. A of Mrinal haloi, showed externally cyanosis, petechial low incidence of suicidal deaths in female should be haemorrhage and froth were found in 64.58%, 27.08%, described in favor of peace, harmony and happiness in 43.75% of the cases respectively, kidney (90.62%) was society, state as well as in country. In present study, most the most common organ showing congestion (26) of the victims were literate Hindu-married females of 21 - In our study incidence of aluminum phosphide (33.33%) 30 years of age belonging to upper-middle socio- and carbamate propoxur (20.0%) poisoning was economic class and majority of women were died due to maximum i.e. among known cases of poisoning followed poisoning. by forate and corrosive compound. Study of KSN Reddy The result of this study indicates that, by not only a strong showed 65.3% incidence of organ phosphorus poisoning. legal support network but also opportunities for economic In study of Vinay Shetty showed incidence of Aluminum independency, essential education and awareness, phosphide maximum, whereas study of Sharma showed alternative accommodation and a change in attitude and maximum incidence of sulphuric acid followed by metallic mindset of society, judiciary, legislature, executive, men irritant, alcohol and insecticides was commonest findings and the most importantly woman herself can lower or during 1980-84. But the trend changed and the incidence prevents the such suicidal deaths. (22) was maximum due to insecticide followed by alcohol The present study includes 45 cases of poisoning in our CONCLUSION institute from May 2007 - April 2009 retrospectively. Pattern of fatal poisoning in present study is more or The cause of death profile is an important set of public less similar to the pattern observed in most of the TABLE Age wise Distribution Education wise Distribution Age group Female Education No of cases 14 – 23 20 (44.44%) Literate 30 (66.66%) 24 – 33 07 (15.55%) Primary 10 (22.23%) 34 – 43 11 (24.44%) Secondary level 12 (26.66%) 44 – 53 04 (08.88%) Higher Secondary level 08(17.77%) 54 – 63 02 (04.44%) Illiterate 15 (33.34%) Total 45 Total 45

Occupation wise Distribution Socioeconomic status wise Distribution Occupation No of cases Socioeconomic No of cases House wives 35 (77.78%) Upper class 06 (13.34%) Laborers 04 (08.88%) Middle class 22 (48.88%) Employed 03 (06.66%) Lower class 17 (37.77%) Student 03 (06.66%) Total 45 Total 45

Religion wise distribution Distribution of poisoning cases according To history of ingestion by victim or relatives Religion No of Cases Hindu 28 (62.22%) Name of ingestion No of cases Muslim 14 (31.11%) substance Christian 02 (04.45%) Acid 04 (08.88%) Unknown 01 (02.22%) Chlorpyriphos 01 (02.22%) Total 45 CUSO4 01 (02.22%) Organophosphorous 09 (20.0%) Unknown substance 20 (44.44%) Unknown liquid 10 (22.23%) Total 45

61 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 Distribution cases according to Distribution of poisoning cases according to presence apparent motive for poisoning of smell in stomach contents during autopsy Apparent Motive No of Cases Type of smell No of cases Mental stress due to unknown reasons 32(71.11%) Bitter 03 (06.67%) Family quarrel 04 (08.88%) Insecticide 20 (44.44%) Mental illness 00 Chronic illness 02 (04.45%) Kerosene 10 (22.23%) Failure in love 01 (02.22%) No smell 12(26.66%) Maladjustment in marriage life 01 (02.22%) Total 45 Failure in Exam 01 (02.22%) Financial problem Cruelty 02 (04.45%) by husband & in-law Dowry 02 (04.45%) Total 45

Distribution of poisoning cases according to Marital Status, Residence and Route of Exposure

Sex Marital status Residence route of exposure unmarried married Widow urban Rural oral inhalation infusion Female 14 31 00 25 20 45 00 00 (31.11%) (68.89%) (55.55%) (44.44%) (100%)

Distribution of cases according to FSL report finding FSL report findings No. of cases Name of Poison Aluminium Phosphide 09 (20.0%) Chlorpyriphos 01 (02.23%) CUSO4 01 (02.23%) Endosulfan 01 (02.23%) Forate 04 (08.88%) Corrosive 04 (08.88%) Kerosene 00 Malathion 02 (04.44%) Monocrotophos 01 (02.23%) Propoxur 15 (33.33%) Zinc phosphide 01 (02.23%) No poison 04 (08.88%) Pending 02(04.44%) Total 45 other studies done by various authors. Our study attitudes, knowledge, and beliefs about pesticides; revealed that most of the victims of fatal poisoning controlling access to dangerous pesticides, including were Hindu married Female of middle socio- developing secure storage practices and improving the economic status who died due to self ingestion of medical treatment of poisonings pesticide poison. More research is needed to better understand Reducing deaths from self-poisoning require prevention suicides involving pesticides in their cultural contexts strategies include treating the problems leading to and to evaluate the effectiveness of intervention suicidal behaviors involving pesticides; changing programs, including assessment of possible substitution of methods.

62 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 REFERENCES 15. PR Shukla, A study of suicide in Varanasi. Indian journal of preventive and social medicine 2001 (JM Dec. 30) 1. Pillay VV. Textbook of Forensic Medicine and Toxicology, 15th edition, 2010, Medico-legal aspects of injuries and death 16. Mohan Kumar T, Kanchan T, Yoganarasimha K, Pradeep Kumar G. Profile of unnatural deaths in Manipal, Southern India 2. KSN Reddy : The Essentials of Forensic Medicine and Toxicology 1994–2004, Journal of Clinical Forensic Medicine, Volume 13, th : 27 edition,2008,ch. -25,P- 466- 474 Issue 3, July 2006, p. 117 – 120 rd 3. Nandy: Principle of Forensic Medicine & Toxicology,3 edition, ch- 17. Sharma BR, Singh VP, Sharma R, Sumedha. Unnatural Deaths in 32, P- 799 - 808 northern india- A profile Journal of Indian Academy of Forensic 4. Vanderhoek w , Konradsen F Athukorala K Wanigadewa T : Medicine, Volume 26, Issue 4, 2004 , P .140- 146. Pesticide Poisoning – a major health problem in srilanka , soc sci 18. Srivastava AK, Arora P. Suspicious Deaths in Newly Married med 1998 ,46 495- 504 Females – A Medicolegal Analysis, Journal of Indian Academy of 5. Eddleston m sheriff MHR & Hawton K : deliberate self harm in Forensic Medicine Volume 29, Issue 4, 2007, p. 62 – 66 srilanka – an over looked tragedy in the developing world br med j 19. Geeta S, Sachidananda M, Sekhar TC, Manju P. Victimiologic 1998, 317 133- 135 Study of Female Suicide, Medico-Legal Update - An International 6. Sinitox revaso de estastica de 1997. Available on http;//www. Journal, Volume 8, Issue 1, 2008 Fiocruz.br 20. Singh AK, Verma AK, Singh K, Singh M, Kumar S. Pattern of Un- 7. De silva p .The logic of attempted suicide and its linkage with natural Deaths in Lucknow, Capital of Uttar Pradesh. Paper human emotion – suicide in srilanka kandy institute of presented in Scientific Session of Forensic Medicon 2010, XXX fundamental studies 1989 1, 25-40. Annual conference of Indian Academy of Forensic Medicine (IAFM) on January 2010 at Nagpur. 8. H.S.Meena, O.P. Murty, J.P. Wali (1994) : Aluminium Phosphide poisoning. Journal of Forensic Medicine and Toxicology vol.XI 21. Kailash UZ, Mugadlimath A, Gadge SJ, Kalokhe VS, Bhusale RG. No.3 and 4, July-Dec. 1994: 19. Study of some socio-etiological aspects of unnatural female deaths at Government Medical College, Aurangabad. Journal of 9. Tandon S.K.; Qureshi G.U.; Pandey D.N.; Aggarwal A : A profile of Indian Academy of Forensic Medicine, Volume 31, Issue3, 2009, poisoning cases admitted in S.N. Medical College and Hospital, p. 210 – 217 Agra, Journal Forensic Medicine and Toxicology1996, XIII. 10-12. 22. Bhattacharjee J, Bora D, Sharma RS, Varghese T. Unnatural 10. Sinha US, Kapoor AK, Agnihotri AK, Shrivastava PC : A profile of deaths in Delhi during 1991. Journal of Medicine, Science and the poisoning cases admitted in SRN Hospital, Allahabad with special Law, Volume 36, Issue 3, July 1996, p. 194 – 198 reference to Aluminium Phosphide poisoning : JFMT vol.16.no.1 Jan to June 1999, 40-43 (Journal of forensic medicine and 23. Bhullar DS, Oberoi SS, Aggrawal OP, Tuli H. Profile of unnatural toxicology). female deaths (between 18-30 years of age) in Government Medical College / Rajundra Hospital, Patiala. Journal of Forensic 11. Morgan H.G., Pocock H., Pottes : The urban distribution of non Medicine and Toxicology, Volume 8, Issue3, 1996, p. 5 – 8 fatal deliberate self harm Br. J. Psych. 126: 319-328, 1975a 24. Accidental and Suicidal deaths in India 2008. National Crime 12. Banerjee G, Nandi DN, Nandi S, Sarkar S, Boral GC, Ghosh A. Bureau of India. Available from: URL: The vulnerability of Indian women to suicide. A field study. Indian J http://ncrb.nic.in/ADSI2008/accidental-deaths-08.pdf and Psychiatry. 1990;32:305–8. Suicidal-deaths-08.pdf 13. Reddy KSN, Gunnar DG, Mokka Prakash, study of op. poisoning 25. Kulshrestha P, Sharma RK, Dogra TD. The Study of Sociological cases in Gulberga Indian Journal of Forensic Medicine and and Demographical Variables of Unnatural Deaths among Young Toxicology, 2006, vol.2 Women in South Delhi within Seven Years of Marriage. Journal of 14. Vinay Shetty, Gurudutta, S. Pawar Profile of poisoning cases in Punjab Academy of Forensic Medicine and Toxicology, Volume 2, district and Medical College Hospital of North Karnataka. Indian 2002 and Medico - Legal Update, Volume 4, Issue 1, 2004, p. 5 - Journal of Forensic Medicine and Toxicology, vol.2, No.2 (2008). 14 26. Mrinal Haloi, Mamata Devi Haloi, Amarjyoti Patowary :Death due to poisoning in District of Kamrup, Assam A Medico-legal Study, J IndianAcad Forensic Med. Jan-March 2013, Vol. 35, No. 1

63 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 Role of Cervical Encirclage in Prevention of Preterm Delivery Dr. Ami V. Mehta*, Dr. Harshad M. Ladola**, Dr. Bina M. Raval***, Dr. Kartik Morjaria****, Dr. Khushali Gandhi*****, Dr. Swati Thakker***** *Asso. Prof., **Prof., ***Asst.Prof., ****IIIrd year Resident, *****II nd year Resident, *****II nd year Resident Department of Ob. & Gyn. Sheth V.S. General Hospital, Ellisbridge ,Ashram Road , Ahmedabad - 7, Gujarat

KEY WORDS : Preterm Delivery,Cervical Incompetence, Cervical Encirclage

ABSTRACT The present study consists of a prospective cohort study of 100 cases of cervical incompetence seen at antenatal OPD of Dept. of OB & Gyn.,at tertiary care hospital and study period was from May 2011 to April 2012.Detailed history was taken. General and obstetric examination was done along with routine hematological and urine investigations. Ultrasound (trans-abdominal and trans-vaginal) was done to rule out Gross Congenital Anomalies, for cervical length and placental localization. Fetal well- being assessment was done by doing daily fetal movement count and serial ultrasound. The incidence of cervical incompetence is 16/1000. Pregnancy loss included both abortions and nonviable preterm deliveries. Most patients presented in early or late second trimester (78%). Only 4% patients presented after 28 weeks of gestation. Majority of patients were asymptomatic (56%) and the most common symptom was abdominal pain (28%).In majority of patients both external (74%) and internal os (56%) were open. Removal of wire was done electively only in 22% of patients whereas emergency removal of wire was done due to labour pains or premature rupture of membranes in majority of patients (78%). Majority of patients had vaginal delivery (74%). LSCS (26%) was performed for various obstetric indications most common was previous uterine scar (42%). There is a significantly improved peri-natal outcome after encirclage. 80% of encirclage cases delivered at or after 36 weeks of gestation as compared to 56% cases following conservative management.

INTRODUCTION · To compare the results of cervical os tightening “Recurrent miscarriage is just like losing your motherhood with complete bed rest along with tocolytic drugs as the ability to have a full term baby and to be a mother is in cases of incompetent cervix. such an intrinsic part of our biological urges…” the exact · Toassess improved pregnancy outcome. words of the woman who had experienced recurrent pregnancy loss. A lot of interest has been taken to unfold MATERIALS AND METHODS the root cause of recurrent abortions and premature The present study consists of a prospective cohort study labour. One of the important causes of such recurrent of 100 cases of cervical incompetence seen at antenatal pregnancy loss is incompetent internal os of cervix. Os OPD of Dept. of OB & Gyn.,of tertiary care hospitaland incompetence had long been recognized as a potential study period was from May 2011 to April 2012.Detailed cause of premature delivery and abortions and has been history was taken. General and obstetric examination was studied and discussed at length and has produced done along with routine hematological and urine rewarding results for both patients and obstetricians. But investigations. Ultrasound (trans-abdominal and trans- during the last few years, a second school of thought vaginal) was done to ruleout gross congenital anomalies, emerged doubting the role of cervical encirclage. By this for cervical length and placental localization. Fetal well- study we tried to evaluate the role of encirclage in being assessment was done by doing daily fetal prevention of preterm delivery and the results are movement count and serial ultrasound. encouraging. Patients seen in OPD fell in two categories: AIMS AND OBJECTIVES First group: (50 patients) · To diagnose and treat patients of incompetent Patients requiring immediate admission and surgical internal os of cervix visiting antenatal OPD. interventions i.e. patients having gestational period of · To evaluate the results of cervical os tightening more than 12 weeks with in cases of incompetent cervix. Correspondence Address : Dr. Ami V. Mehta “Shyam”, B/S Bhaktimata Society, B/h. New Vikasgruh Bhatha, Paldi, Ahmedabad 380007. Email : [email protected] 64 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 · Open internal os and or effaced cervix. is becoming an important tool of diagnosis of cervical incompetence, many patients can be benefitted in terms · Patients having bulging membranes through of increased pregnancy duration by offering them timely open os. cervical encirclage before clinical symptoms and signs · History of previous full term delivery effected appear. from cervical encirclage irrespective of Out of 100 patients studied 18 were primigravidae and 82 condition of cervix in this pregnancy. were multigravidae so incompetence can be congenital Second group: (50 patients) as it is also seen in primigravidae patients. · Patients with no detectable abnormal cervical TABLE NO. I Previous pregnancy loss findings but with past history of mid trimester No. of previous loss 0 1 2 3 abortions. No. of patients 70 14 14 2 · These were seen every 15 days in OPD and Pregnancy loss included both abortions and nonviable each time condition of cervix was assessed. USG was done to assess cervical length. preterm deliveries. Most patients presented in early or late second trimester, · They were advised complete bed rest with average age being 17 weeks. Only 4 patients presented elevation of foot end. If in second trimester cervix was dilated and/or effaced patient was after 28 weeks of gestation. admitted for encirclage. TABLE NO. II Condition of cervix at the time Any genital or urinary tract infections were appropriately treated. The patients were explained about the type of of ultrasonography operation, success rate, limitations, complications and Cervical 1.5 to 2.5 cm 2.5 to 3.5 cm >3.5 cm necessity to remove it earlier if premature labour pain Length 18 44 38 starts. Cervical encirclage was done by McDonald's technique1 . Post operatively patients were given complete Cervical Increasing Decreasing bed rest, foot end elevation, tocolytics and on second post obliquity with strain with strain op day per speculum examination was done to rule out leaking of amniotic fluid, bleeding or infection. The 42 58 patients were discharged on second or third post- Status of Open /patulous Closed operative day. Post operatively the patients internal os56 44 werecounselled for regular follow-up and to report immediately if she had any leaking, bleeding of if labour Bulging Present Absent pain starts. The wire was removed electively at 37th to 38 th membranes 11 89 week or if the patient presented with true labour pains. OBSERVATIONSAND DISCUSSION: TABLE NO. III Term of pregnancy at the time of circlage Due to lack of unanimous criteria for diagnosis of cervical Term of 15 17 18 20 22 24 25 26 27 incompetence there are varied incidence quoted by pregnancy various authors: at time of circlage Picot2 and co-workers 3/1000 deliveries (in weeks) 3 Barter and co-workers 0.6/1000 deliveries No. of 7 1 1 12 7 6 4 9 3 Mayo's clinic4 1-2% i.e. 10 to 20/1000 deliveries patients TeLinde's Textbook of Operative Gynecology 10th edition 1% i.e 10/1000 deliveries. In our study majority os tightening procedure was done in second trimester as majority of patients had taken first Present study 16/1000 deliveries i.e. 1.6% antenatal visit in the second trimester. The procedure was A total of 6250 patients had delivered during the above performed after ruling out congenital anomalies.Average mentioned time duration. All the units of this hospital had duration being 22weeks. almost similar protocols for the management of cervical insufficiency. The incidence appears higher because our Majority of patients were asymptomatic and the most hospital being tertiary centre most of abnormal and common symptom was abdominal pain. The abdominal specially selected patients are referred and as ultrasound pain was not associated with uterine irritability.

65 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 TABLE NO.IV Condition of cervix at the time of Majority of the patients who had undergone encirclage os tightening had birth weight between 2.6 to 3.0 kg with good perinatal Condition of cervix No. of patients Percentage outcome. There is a co-relation with findings of WHO External os review8 that following cervical encirclage there is an Open 38 76 improvement in peri-natal outcome compared with the Closed 12study group. Patulous 11 22 TABLE NO. VI Comparison between conservative Internal os and encirclage cases. Open 27 54 No. of 28 30 32 33 34 35 >=36 Closed 23 46 weeks Cervical tear 13 26 Conservative 1 2 2 4 7 6 28 Cervical ectropion 12 Encirclage - - 1 3 1 5 40

In majority of patients both external and internal os were There is a significantly improved peri-natal outcome after open.Various factors which influence the outcome after encirclage. 80% of encirclage cases delivered at or after circlage operation are the gestational period at which 36 weeks of gestation as compared to 56% cases tightening is done, the method of tightening and the following conservative management. There is a co- condition of the cervix.5 relation with findings by Bachmann et al910 , Althusiuis et al 11 Postop recovery was uneventful for majority of patients and Odibo et al which all state that cervical encirclage (74%) showing that nylon wiring is a relatively safe has a definite role in preventing preterm delivery. procedure with minimal complications. None of the patients in the conservative group were subjected to encirclage. Removal of wire was done electively only in 22% of patients whereas emergency removal of wire was done due to labour pains or premature rupture of membranes in majority of patients (78%). Average interval between removal of wire and delivery was 6 days. Prolongation of pregnancy after removal of wire ranged from 12 hours to 13 days. Maximum interval was found in patients having elective removal of loop. Figure I Open Internal OS With A “ U “ Shaped Cervix. Majority of patients had vaginal delivery. LSCS was performed for various obstetric indications. Harger6 showed that caesarean section rates and sub sequent maternal morbidity were more with Shirodkar's7 operation than with McDonald's operation. Majority of caesarean section were due to previous uterine scar(42%). TABLE NO. V Birth weight Birth weight (in kg.) Mode of treatment Conservative Circlage <1.5 kg 3 1 1.5 to 2.0 kg 4 4 2.1 to 2.5 kg 22 13 Figure II 2.6 to 3.0 kg 15 23 3.1 to 3.5 kg 6 9

66 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 CONCLUSION REFERENCES · Diagnosis should be made on the basis of past 1. McDonald, I. A.: Suture of the cervix for inevitable miscarriage. J. obstetric history, present clinical findings and Obstet. &Gynaecol. Brit. C'wlth., 64: 346-350, 1957. 2. Picot et al: A consideration of the incompetent cervix. J. Ob &Gy, ultrasonographic findings. 1959;78;786 · Timely diagnosis and treatment improves peri- 3. Baden and Baden: Cervical incompetence : current therapyAm.J. natal outcome drastically. Ob Gy1960:79:545-51 4. Wikipedia encyclopedia. · Foetal salvage rate improved with cervical 5. Deshpande VV, Bhattacharya MM.The place of elective circlage encirclage as compared to conservative group. operation for cervical incompetence during pregnancy. J Postgrad Med 1985;31:155 · Out of all surgical procedure of encirclage, 6. Harger, J. H.: Comparison of success and morbidity in cervical McDonald's procedure is very simple, effective, cerclage procedures. Obstet. Gynaecol. Survey, 36: 189-190, less traumatic with minimum complications. So it 1981 is the method of choice in our study. 7. Shirodkar, V. N.: A new method of operative treatment for habitual · abortions in the second trimester of pregnancy. Antiseptic, 299: Circlage should be done between 16 to 22 weeks 52-54, 1955 (second trimester) of pregnancy after congenital 8. Huy NVQ. Cervical stitch (cerclage) for preventing pregnancy loss anomalies are ruled out. in women: RHL commentary (last revised September 2007). The · WHO Reproductive Health Library, Geneva: World Health Timely removal of wire is also necessary to Organization. prevent cervical trauma, either electively or as 9. Bachmann LM, Coomarasamy A, Honest H, Khan K, Horten soon as labor pains start. Centre, University of Zurich: Elective cervical cerclage for prevention of preterm birth : a systematic review. · Mode of delivery (vaginal/caesarean section) is AotaObstetGynecol Scand. May 2003 82(5): 398-404. not related to treatment modalities either 10. Althuisius SM, Dekker GA, Hummel P van Geijn: Cervical conservative or circlage. incompetence prevention randomized cerclage trial: emergency cerclage with bed rest versus bed rest alone. Am J ObstetGynecol · In our study perinatal outcome rate was 80% in 2004; 191:1311-7. case of encirclage compared to conservative 11. Odibo AO, Elkousy M, Ural SH, Macones GA: Prevention of group 56%, hence proving that os tightening has preterm birth by cervical cerclage compared with expectant got excellent result in cases of cervical management : a systematic review. ObstetGynecolSurv, 2003 February, 58(2): 130-6. incompetence.

67 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 Unstable Intertrochanteric Fractures In High Risk Elderly Patients Treated With Primary Bipolar Hemiarthroplasty: Retrospective Case Series Dr. Nikunj Maru*, Dr. Kishor Sayani** *Assistant professor, **Associate professor Orthopedics department, P.D.U. Medical College, Rajkot.

KEY WORDS : Hemiarthroplasty, unstable intertrochanteric fractures, high risk elderly patients

ABSTRACT Background: The management of unstable osteoporotic intertrochantric fractures in elderly is challenging because of difficult anatomical reduction, poor bone quality, and sometimes a need to protect the fracture from stresses of weight bearing. Internal fixation in these cases usually involves prolonged bed rest or limited ambulation, to prevent implant failure secondary to osteoporosis. The purpose of this study is to assess the mortality and morbidity and post operative complication in high risk Intertrochanteric fractures treated by cemented bipolar. Material and methods: We retrospectively studied, 28 elderly patients with preoperative ASA grade-III with unstable intertrochanteric fractures (AO/OTA type 31-A2.2 and 31-A2.3 and Evans type III or IV) by primary hemiarthroplasty using a cemented bipolar prosthesis. All patients were operated by the same surgical team. Bipolar implants were cemented (tapered design, 2nd generation cemented technique, standard length) and trochanteric comminution was circlage to restore abductor mechanism. The assessment was done with emphasis on perioperative mortality, morbidity and complications related to prolonged bed rest. Results: Mean patient age was 75.6 (64-91) years and mean follow-up was 22.3 (5-48) months. 10 patients were able to walk with a walker in the first post-operative week. Rehabilitation was easier and faster and post op morbidity like pressure sore pulmonary complication was significantly low (P<0.05). The mortality (2/28) was significantly low. We obtained 11 excellent and 10 good results after 12 months according to the Harris hip-scoring system. Conclusion: Primary Bipolar Hemiarthroplasty may be a better alternative treatment for unstable Intertrochanteric fractures in elderly moribund patients.

INTRODUCTION primary bipolar arthroplasty rather than internal fixation Intertrochanteric fractures are major cause of disability could perhaps return these patients to their preinjury level and death in elderly. The incidence of all hip fractures is of activity more quickly, thus obviating the postoperative approximately 80 per 100,000 persons and is expected to complications caused by immobilization or failure of the double over the next 50 years as the population ages1 . implant. Intertrochanteric fractures make up 45% of all hip Intramedullary interlocking devices have shown reduced fractures. tendency for cut-outs in osteoporotic bones and also have Stable fractures can be easily treated with osteosynthesis better results in cases of unstable intertrochanteric 4 with predictable results. However, the management of fractures. However, the role of the intramedullary devices unstable intertrochantric (Evans type III or IV and AO/OTA in unstable osteoporotic and severely comminuted type 31-A2.2 and 2.3).2,3 fractures in elderly patients is a intertrochanteric fractures is still to be defined. challenge because of difficulty in obtaining anatomical Endoprosthetic replacements have also been shown to reduction and associated with high rates of morbidity and achieve early rehabilitation of the patient and good long- 5,6,7,8 mortality, although the results have improved with the use term results. However, an ideal treatment method is of internal fixation. In these patients however, still rather controversial because of the poor quality of comminution, osteoporosis, and instability often preclude bone mass, comorbid disorders, and difficulty in the early resumption of full weight bearing. Treatment with rehabilitation of these patients.

Correspondence Address : Dr. Nikunj D. Maru (M.S. Ortho) Orthopedics department, P.D.U. Medical College, Rajkot. E-mail address: [email protected] 68 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 Recent publications indicate concern with excessive used in five cases which were severely comminuted. sliding of these fixation devices when used in unstable (Anteversion - retroversion of the prosthesis - was intertrochanteric fractures, the excessive sliding can determined using the lesser trochanter as a guide after result in unacceptable shortening and external rotation temporarily reducing the lesser trochanter anatomically.) deformity of the limb. Bendo et all9 reported that most of The femoral canal was broached with appropriate the patients with moderate or severe collapse had poor anteversion. A fixed bipolar prosthesis was then inserted functional results. Elderly patients often are unable to and trial reduction was done. With the trial prosthesis in cooperate with partial weight bearing, or if allowed full situ traction was applied to the leg and compared with the weight bearing, voluntarily limit loading of the injured limb. opposite leg for limb length equality. We used the second- To allow immediate postoperative full weight bearing and generation cementing technique and cement restrictor in to avoid excessive collapse at the fracture site, some all cases. Once the prosthesis was fixed, the broken surgeon recommended prosthetic replacements for trochanter and calcar were again retightened by unstable intertrochanteric fracture.7 tensioning the wire cables. The sleeve of gluteus medius, The purpose of this study was to determine whether greater trochanter, and vastus medialis if reconstructed cemented hemiarthroplasty using a standard femoral was now reattached to the shaft by additional wires. The stem is a reasonable alternative method of treatment for short external rotators were then sutured back using bone elderly patients in unstable intertrochanteric fracture to tunnels in the greater trochanter with the closure of the reduce mortality and morbidity in term of day of full weight superficial layers, as routine over a suction drain after bearing and complications related to prolonged bed rest. achieving hemostasis. MATERIAL AND METHODS Prophylactic first-generation cephalosporin and low- molecular-weight heparin (enoxaparin) was started 12 h Between August 2009 and September 2011, 28 patients before operation. Walking exercises were started on the who were older than sixty five years, associated with second post-operative day. Patients were followed in 3- preexisting systemic disease, who are high risk for month intervals for the first year and 6-month intervals in anaesthesia (ASA Grade III &IV),osteoporosis as asses the second year. During the follow-up patients were by Singh's index,(All patients had confirmed osteoporosis evaluated according to the Harris hip-scoring scale. on the preoperative bone mineral density scan confirming 10 (Patient was evaluated using the Harris hip score (HHS) with the WHO criteria ) The fractures were classified and were graded as <70 poor, 70-79 Fair, 80-89 Good and according to AO/OTA and Evans classification. Only 90-100 Excellent). We used the Gingras criteria in AO/OTA type 31-A2.2 and 31-A2.3 and Evans type III or 11 determining radiographic loosening . For acetabular IV fractures were included in this study and who had been erosion the distance from the head of the prosthesis to the independently mobile before sustaining an unstable superior dome of the acetabulum was measured on the intertrochanteric fracture were treated by the same immediate post-operative and follow-up surgical team at P.D.U. Medical college and hospital roentgenograms. Rajkot. To determine movements of the bipolar head we Patients who were unable to walk before the fracture, who measured the angle between a line parallel to the edge of were younger than sixty five years old, not associated with the outer cup and a line parallel to the longitudinal axis of any medical disease or who had stable fracture with intact the femoral stem. We measured the angle between these lesser trochanter been not included in the study. two lines with the hip in neutral position and in 45° of Operative technique: We used a posterolateral modified abduction. Gibbson's approach in lateral position. The fracture RESULTS anatomy was assessed and a cut was taken high up in the neck (almost subcapital level) to facilitate removal of the There were 13 women and 15 men with an average age of femoral head. With the removal of the head, the fracture 75.6 (64-91) years. The Singh index was grade 3 in 5 now had three main fragments namely the greater patients, grade 2 in 12, and grade 1 in 11.Average interval trochanter, the lesser trochanter, and the shaft with the between occurrence of fracture and hospitalization was retained portion of the neck of femur. Thus, the 1.4 days and average interval between hospitalization reconstruction was made between greater trochanter, the and operation was 5.7 days. Numerous medical problems lesser trochanter, and the shaft were wired together using were noted upon admission, including hypertension, steel wires in 23 cases while only ethibond sutures were diabetes mellitus, heart disease, neurological disease, haematological disease, lung disease and others. 69 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 The average surgery time was 71 min (range, 55-88 min) prosthesis. In 2 patients we found the circlage wire used with an average intraoperative blood loss of 350 ml for the greater trochanter had broken. There was no (range, 175-500 ml). Out of the 32, two patients expired dislocation or aseptic loosening. One patient developed due to unrelated causes (both due to myocardial pneumonia which settled down with intravenous infarction). The remaining 30 patients having a minimum antibiotics. One patient had a periprosthetic fracture 6 one year follow up were evaluated and data was further months after surgery which was treated with a locking analyzed for only these 28 patients. The minimum follow compression plate. The fracture healed and the patient up was average of 24.5 months (range, 18-39 months). went on to have an excellent result. The patients started full weight bearing at an average 4.2 DISCUSSION days after surgery (range, 3-8 days). One patient refused Displaced, unstable, severely comminuted to walk after surgery and had a poor result (HHS 58). The intertrochanteric fractures are associated with notable average stay in the hospital was 10.96 days (range, 5-21 morbidity and mortality in elderly patients. Internal fixation days). One of the patients developed bed sore has drastically reduced the mortality associated with postoperatively, and required a week more of hospital intertrochantric fractures12 ; however; early mobilization is stay, till the healing of the sore. This patient was operated still avoided in cases with comminution, osteoporosis, or on 5th day post injury and did not have a pre operative bed poor screw fixation. Primary hemiarthroplasty offers a sore. modality of treatment that provides adequate fixation and Atotal of 11 patients were graded as excellent, 10 patients early mobilization in these patients thus preventing as good, 4 as fair, 3 as poor results. At latest follow-up postoperative complications such as pressure sores, (mean 24.5 months, range 18 months to 39 months), the pneumonia, atelectasis, and pseudo arthrosis. The Indian mean HHS was 84.89.72 (range, 58-97). perspective regarding the use of primary arthroplasty as a At last follow-up, 16 patients were walking without any aid, modality of treatment for severe comminuted unstable 10 patients had a limp and used a stick for walking, 1 intertrochantric fractures is been commented on by few 13,14 patient used a walker, and 1 was wheelchair bound. 5 authors; however, our case series reporting the Indian patients had shortening of the operated limb with an experience (Mid TermResults) with this technique. average shortening of 1.1 cm (range, 5-15 mm) which Hemiarthroplasty has been used for unstable was well compensated by giving a shoe raise. A total of 12 intertrochanteric fractures since 1971, however less patients had an abductor lurch at 3-month follow-up; frequently as compared to femoral neck fractures. It is however, only 3 patients had abductor muscle weakness initial use was as a salvage procedure for failed pinning or with a positive Trendelenberg test at final follow-up. Most other complications. Tronzo claimed to be the first to use of these patients however could walk well with the use of a long, straight-stemmed prosthesis for the primary stick. treatment of intertrochanteric fractures.5 Rosenfeld, Among the patients with poor results, one patient had a Schwartz, and Alter reported good results with the use of superficial wound infection which settled down with a the Leinbach prosthesis. Since then there are multiple course of intravenous antibiotics for 2 weeks. However, studies showing good results using this technique. Stern the patient continued to have diffuse pain along the and Goldstein reported on 29 patients with incision site and walked with a limp. The second patient of intertrochanteric fractures treated with the Leinbach poor results also had pain and limp, but we could not find prosthesis with excellent results in 88%. They reported a any obvious reason for the pain. The patient with the failed deep infection rate of 6.8% but no dislocations. Stern and result was a case of Alzheimer's disease. The patient did Angerman16 reported on 105 cases of unstable not cooperate with the physiotherapy program and intertrochanteric femoral fractures treated with Leinbach refused to walk postoperatively. Eventually, the patient prosthesis. They reported a deep infection rate of 2.8% developed a severe adduction contracture and was but made no comments on dislocations. They obtained a wheelchair bound. 94% success rate in returning the patient to the pre- Deep infection developed in one patient during the 13th fracture ambulatory status. month post-operatively, and the prosthesis was removed The earliest comparison of internal fixation and 1 year later. There was one case of acetabular erosion, 4 hemiarthroplasty was done by Haentjens et al.16 showing patients with non-union of the greater trochanter and 6 a significant reduction in the incidence of pneumonia and with leg-length discrepancy due to high seating of the pressure sores in those undergoing prosthetic

70 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 replacement. In a comparative study of cone Mortality at 1 yr hemiarthroplasty versus internal fixation, Kayali et al. Stern et al17 14% reached the conclusion that clinical results of both groups Green et al19 20% were similar. Hemiarthroplasty patients were allowed full weight bearing significantly earlier than the internal Chris Grismud15 10.3% fixation patients. Harwin et al6 NR Broos et al.7 concluded that the operative time, blood loss, Haentgens et al16 35% and mortality rates were comparable between the two Chan et al8 7.3% groups, with a slightly higher percentage (73% versus Current study 14% 63%) of those receiving a prosthesis considered to be In the short term, unipolar or bipolar hemiarthroplasty pain free. The functional outcome was comparable seem to give better results than open reduction and between both groups. Stappaerts et al. found no internal fixation in the treatment of unstable difference between two groups except a higher intertrochanteric hip fractures in terms of mortality and transfusion need in the replacement group. In our series morbidity rates, complications, early rehabilitation and the average blood loss was 350 ml with only six patients returning to daily living activities. Long-term problems requiring postoperative blood transfusion and there was such as loosening, protrusio, stem failure, late infections no incidence of dislocation. and late dislocations have not been seen in these series. While these theoretically are potential problems they are Rodop et al.18 in a study of primary bipolar hemiprosthesis seen usually years after the surgery. Although the for unstable intertrochanteric fractures in 37 elderly average patient age in these series was between 74 and patients obtained 17 excellent (45%) and 14 good (37%) 82 years, shorter-term complications seem to be more results after 12 months according to the Harris hip-scoring important than long-term ones. Because life expectancy system. A total of 18 out of 23 patients in our study had a increases in all countries, long-term disadvantages of the good to excellent result (71%). If the patients with a fair hemiarthroplasty may outweigh its short-term result were also included, the percentage goes up to 91%. advantages. Thus the results of this modality of treatment are definitely Delay in surgery is an important predictor for mortality in promising. patients with proximal femur fracture and also of the Green19 reported on 17 patients who had a primary head- postoperative morbidity. We in our study, however, could not comment on these points because of small sample neck bipolar prosthetic replacement for unstable size and this is one of the limitations of our study. Further, intertrochanteric femoral fractures. Average patient age inhomogeneous population in terms of existing co- was 82.2 years, average time to ambulation was 5.5 days, morbidity and retrospective nature of our study are the and average follow-up time was 13.2 months. Two other limitations. patients had non-union of the greater trochanter. Overall CONCLUSION results were uniformly good with no infections or Thus in conclusion, primary hemiarthroplasty does dislocations. The mortality rate was 20% at the end of the provide a stable, pain-free, and mobile joint with first year. acceptable complication rate as seen in our study; 20 P. Florian Geiger; P.Monique Zimmermann-Stenzel however a larger prospective randomised study found that Mortality was significantly influenced by Age, comparing the use of intramedullary devices against Gender, Amount of Co-morbidities but not by fracture primary hemiarthroplasty for unstable osteoporotic classification.43 fractures will be needed. Mortality rate of bipolar arthroplasty and internal fixation However, bipolar hemiarthroplasty for unstable of different study compare with current study are shown in intertrochanteric fractures was used as a salvage procedure after primary fixation failure, but primary following table. bipolar hemiarthroplasty may be used as a better (Journal of arthroplasty- April2005,Chris Grimsud, Raul J. alternative treatment for unstable osteoporotic 15 Monzon et al ) Intertrochanteric fractures in elderly moribund patients for early ambulation and good functional results.

71 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 REFERENCES 12. White BL, Fisher WD, Laurin CA. Rate of mortality for elderly patients after fracture of the hip in the 1980's. J Bone Joint Surg Am 1. JD Zuckerman: Hip fracture. N Engl J Med 1996; 334:1519-1523 1987;69:1335-40 2. Evans EM. The treatment of trochanteric fractures of the femur. J 13. Babhulkar SS. Management of trochanteric fractures. Indian J Bone Joint SurgAm 1949;31:190-203 Orthop 2006;40:210-8 3. Marsh JL, Slongo TF, Agel J, Broderick JS, Creevey W, DeCoster 14. Kulkarni GS, Limaye R, Kulkarni M, Kulkarni S. Intertrochanteric TA, et al. Fracture and dislocation classification compendium: fractures. Indian J Orthop 2006;40:16-23 Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma 2007;21:S1-133 15. Grimsrud C, Monzon RJ, Richman J, Ries MD. Cemented hip arthroplasty with a novel cerclage cable technique for unstable 4. Haynes RC, Poll RG, MilesAW, Weston RB. Failure of femoral head intertrochanteric hip fractures. JArthroplast 2005;20:337-43 fixation: A cadaveric analysis of lag screw cut-out with the Gamma locking nail andAO dynamic hip screw. Injury.1997;28:33741 16. Haentjens P,Casteleyn PP,De Boeck H, Handelberg F,Opdecam P. Treatment of unstable intertrochanteric and subtrochanteric 5. Tronzo RG. The use of an endoprosthesis for severely comminuted fractures in elderly patients. Primary bipolar arthroplasty compared trochanteric fractures. Orthop Clin NorthAm 1974;5:679-81 with internal fixation. J Bone Joint SurgAm 1989;71:1214-25 6. Harwin SF, Stern RE, Kulick RG. Primary Bateman-Leinbach 35. Kayali C, Agus H, Ozluk S, Sanli C. Treatment for unstable bipolar prosthetic replacement of the hip in the treatment of intertrochanteric fractures in elderly patients: Internal fixation unstable intertrochanteric fractures in the elderly. Orthopedics versus cone hemiarthroplasty. J Orthop Surg (Hong Kong) 1990;13:1131-6 2006;14:240-4 7. Broos PL, Rommens PM, Deleyn PR, Geens VR, Stappaerts KH. 36. Rosenfeld RT, Schwartz DR, Alter AH. Prosthetic replacement for Pertrochanteric fractures in the elderly: Are there indications for trochanteric fractures of the femur. J Bone Joint Surg Am 1973; primary prosthetic replacement? J Orthop Trauma 1991;5:446-51 55:420 8. Chan KC, Gill GS. Cemented hemiarthroplasties for elderly patients 17. Stern MB, Angerman A (1987) Comminuted intertrochanteric with intertrochanteric fractures. Clin Orthop Relat Res fractures treated with a Leinbach prosthesis. Clin. Orthop 218:75- 2000;371:206-15 80 9. Bendo JA, Weiner LS, Strauss E, and Yang E: Collapse of 18. Rodop O, Kiral A, Kaplan H, Akmaz I. Primary bipolar intertrochanteric hip fractures fixed with sliding screws. Orthop Rev hemiprosthesis for unstable intertrochanteric fractures. Int Orthop Suppl: 30-37, 1994 2002;26:233-7 10. Kanis JA. Assessment of fracture risk and its application to 19. Green S, Moore T, Proano F (1987) Bipolar prosthetic replacement screening for postmenopausal osteoporosis: Synopsis of a WHO for the management of unstable intertrochanteric hip fractures in report. Osteoporosis Int 1994;4:368-81 the elderly. Clin Orthop 224:169-177 11. Gingras MB, Clarke J, Evarts McC (1980) Prosthetic replacement in 20. P.Florian Geiger; P.Monique Zimmermann-Stenzel. Mortality was femoral neck fractures. Clin Orthop 152:147-157 significantly influenced by Age, Gender, and Amount of Co- morbidities but not by fracture classification. Arch Orthop trauma Surg.2007-SEPT.

72 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 Role of ultrasonography in evaluation of orbital lesions. Dr. Hemang D. Chaudhari*, Dr. Gurudatt N. Thakkar***, Dr. Viplav S. Gandhi**, Dr. Parth J. Darji*, Dr. Hiral K. Banker*, Dr. Hemadri Rajwadi **Professor & HOU, ***Associate Professor, * 3rd year residents. Department of radiology, Smt. S.C.L. Municipal General Hospital, Smt. N.H.L. Municipal Medical College, Ahmedabad-380018 KEY WORDS : Ultrasonography; Orbital Lesions.

ABSTRACT Ultrasonography is non-invasive non-ionizing imaging modality which provides all information, not available by any other means. The aim of this study is to show how sonography is useful in detection of orbital lesions and also to highlight its usefulness as a simple and cost effective diagnostic tool. Total100 cases were included in this study. All images were obtained using a standard USG machine equipped with high-frequency probe. Both eyes scanned thoroughly for comparison. At the end of study we concluded that ultrasonography is highly reliable, easily performed examination technique which is very helpful for all patients presented with eye symptoms, can guide further diagnostic testing and monitor the patient's response to therapy.

INTRODUCTION METHODS AND MATERIALS Ultrasonography has become an important diagnostic This was a case series study which included 100 patients technique in ophthalmology, particularly during past few with eye symptoms out of which 58 were male and 42 years. Ultrasound was first used in the year 1956 by two were female patients. All images were obtained using a American ophthalmologists, Mundts and Hughes. The standard USG machines (NIDEK echoscan model US- experience about cross-sectional B-scan display of the 2500 and Wipro GE logiq P5 premium 3) equipped with a eye was reported by Baum and Greenwood (1958).[1] 7.5-10 MHz real-time high-frequency probe. The probe The cystic nature of the eye, its superficial location, and was placed over the closed eyelid after application of high-frequency transducers make it possible to clearly coupling gel. Both eyes scanned thoroughly for show normal anatomy and pathology of eye and orbits [2]. comparison. Sonography is used more commonly by ophthalmologists OBSERAVATIONS to evaluate the eye, particularly when direct examination by slit-lamp and fundoscopy is not sufficient. Detailed Chart I shows sex distribution of the patients cross-sectional anatomy of the entire globe is possible included in study. with conventional sonographic equipment [2,3] Doppler and A-mode sonography [4] are reported to be useful in characterizing masses. AIMS AND OBJECTIVES 1. To evaluate the role of USG in orbital diseases, in differentiating ocular and extraocular diseases. 2. Toevaluate orbital trauma 3. Localization of intraocular foreign body 4. Toestablish etiology of proptosis 5. To assess tumor location, configuration, extent and relationship to adjacent structure. 6. To evaluate the role of USG in cases with opaque light conducting media where direct vision by ophthalmoscopy is impossible. Out of 100 patients 58 patients were male and 42 were female.

Correspondence Address : Dr. Hemang D. Chaudhari Doctor Quarters, Room No 22, Smt. S.C.L. Municipal General Hospital, Saraspur, Ahmedabad, 380018. 73 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 Chart II shows the age distribution of the patients. Table II Incidence of intraocular pathologies (N=69) No. Pathology Patients Percentage (N=69) 1 Vitreous haemorrhage 14 20.29% 2 Vitreous degeneration 10 14.45% 3 Vitreous detachment 4 5.80% 4 Choroidal detachment 1 1.45% 5 Retinal detachment 15 21.74% 6 Foreign body 2 2.90% 7 Dislocated lens 3 4.35% 8 Scleritis 2 2.90% 9 Ruptured globe 1 1.45% 10 Retinoblastoma 2 2.90% Ocular pathologies were observed predominantly 11 Endophthalmitis 7 10.14% in 4th and 5th decade of life. 12 Coats’ disease 1 1.45% Chart III shows side of involvement of eye. 13 PHPV 1 1.45% 14 Optic disc 2 2.90% 15 Hyphema 2 2.90% 16 Normal 6 8.70% Most common intraocular pathology was vitreous followed by retinal pathology. Table III Incidence of various Extraocular pathologies (N=31) No Pathology Patients Percentage (N=31) 1 Retro-orbital abscess 7 22.58% 2 Haematoma 9 29.03% Right eye, left eye was involved in 36 and 54 cases 3 Graves’ disease 3 9.68% respectively while 10 cases showed both eye involvements. 4 Dermoid 2 6.45% 5 Metastatic tumour 1 3.23% Table I : Incidence of presenting complaints 6 Optic nerve tumour 1 3.23% in the patients. 7 Others 8 25.80% Presenting Total Cases Percentage Most of the extra ocular pathologies were retroorbital Complaints (N=100) abscess and hematoma. Diminution Of Vision 32 32 Figure -1 Pain, Redness 24 24 Proptosis 16 16 Trauma 20 20 Discharge 4 4 Leukocoria 4 4

The main complaints were diminution of vision (32%), pain and redness (24%). Out of 100 patients studied intraocular pathologies were observed in 69 patients while extraocular pathologies were noted in 31 patients.

74 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 Fig 1-A : 16 year old male patient with fresh vitreous Figure-3 haemorrhage. Sonography shows vitreous echoes in form of small dotes and short lines, distinct after movement. Fig 1-B : 48 year old woman with posterior vitreous detachment. Sonography shows thin undulating membrane not attached to optic disc. Fig 1-C : 34 year male with closed funnel shaped retinal detachment.Usg shows membrane attached to optic disc posteriorly and anteriorly to ora serata with dense echoes within funnel. Fig 1-D : 49 year old man with tractional retinal detachment. Sonography shows uniform V shaped membrane attached to optic disc posteriorly. Fig 3-A : 50 year old male patient with graves' diease. Sonography shows thick infiltrated inferior rectus muscle. Figure-2 Fig 3-B : 12 year old male patient with retro-orbital hematoma. Sonography shows mix reflective lesion in retro orbital space Fig 3-C : 2 year old female patient with persistent hyperplastic primary vitreous. (PHPV) Sonography shows dense echogenic band extending from posterior capsule of lens anteriorly to the optic disc posteriorly. Band is thin anteriorly near lens and is broad near optic disc. Fig 3-D : 11 year old male patient with coats' disease. High resolution ultrasonography image shows moderate density echoes within posterior vitreous, suggestive of exudation. Membranous echoes with limited after movement attached to disc, suggestive of retinal detachment. Doppler USG showed abnormal retinal vessels.

DISCUSSION Fig 2-A : 2 year old girl with retinoblastoma. Irregular dome shaped mass with mix echotexture and calcification INTRAOCULAR PATHOLOGIES within the vitreous cavity. ANTERIOR SEGMENT Fig 2-B : 67 year old male patient with choroidal Hyphema : melanoma. Sonography shows well defined uniform Hyphema is a collection of blood in the anterior chamber echotexture lesion in subretinal space. and may occur from conjuctival or sclera vessels due to minor trauma. Fig 2-C : 66 year old woman with optic disc drusen. In our study, two cases of hyphema were clinically Sonography shows characteristically hyperechoic spots diagnosed and poorly visualized on ultrasonography at fundus and particularly helpful in revealing drusen because of poor visualization of anterior chamber. buried at optic nerve which are otherwise invisible on POSTERIOR SEGMENT fundoscopy. VITREOUS PATHOLOGY Fig 2-D : 55 year old male patient with posterior Vitreous Haemorrhage dislocation of lens. Sonography shows multiple localised In normal eye, the vitreous is acoustically clear. In vitreous dense echoes noted within vitreous cavity. hemorrhage, small granular dot like echoes are seen on

75 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 the display screen as the beam is directed at involved RETINAL PATHOLOGY areas [5]. "Asteroid hyalosis" i.e. accumulation of calcium Retinal detachment soaps in vitreous can mimic a dense central vitreous It is of two types, hemorrhage but can be differentiated by a rapid shift of gaze as the vitreous echoes show prolonged after 1. Rhegmatogenous (arising from retinal break or tear) movements. Total 14 cases of hemorrhage were noted in 2. Non-rhegmatogenous (or secondary retinal our study (Fig 1 A). These hemorrhages either cleared detachment) completely on follow up (2-8 weeks time) or appeared in Rhegmatogenous retinal detachment appears as thin form of organized membrane. continuous acoustically opaque line of echoes separate Vitreous Detachment from and anterior to the echoes from the wall of the globe Separation of vitreous from retina could be diagnosed on [7]. Old retinal detachment appears as a thick membrane ultrasound correctly in 4 cases in our study. (Fig 1-B) which often shrinks to form a chord like structure from Posterior vitreous detachment presented either a thin optic disc to ora serrtata thus taking a "FUNNEL- SHAPED" or "MORNING GLORY" configuration. (Fig 1 sheet of echoes along the posterior hyaloid interface C)Non-rhegmatogenous retinal detachment shows a usually inserting into retina just anterior to equator and solid choroidal mass behind the elevated retinal occasionally showing attachment to optic disc or diffuse detachment. Posterior to detached retina, an acoustically or dispersed echoes to one or other vitreous compartment opaque (white) mass lesion is seen instead of an [6]. acoustically clear space. Vitreous Degeneration 15 cases of retinal detachment were observed in our 10 cases of abnormal vitreous echoes due to study. V-shaped or Y-shaped membrane (Fig 1 C, Fig 1 D) degeneration are observed; out of these, 5 cases due to attached to ora serrata anterioly and optic nerve head senile degeneration, 2 cases due to high myopia and 3 posteriorly and restricted mobility on dynamic scanning cases due to diabetes. Ultrasonically 5 cases presented were present. with dispersed echoes, 3 seen as localized echoes and 1 Retinoblastoma as diffuse echoes. [6] It is the commonest primary intraocular tumour of Persistent hyperplastic primary vitreous(PHPV) childhood occurring 1 in 20,000 live births. It presents with A retrolental mass composed of mesenchymal leucocoria (white pupil) in its late stage. 94% of reported fibrovascular tissue is connected to the optic nerve head cases were sporadic but in 6% positive family history of by persistent hyaloids vessels. The lesion is usually retinoblastoma was available with autosomal dominant unilateral. incomplete penetrance. Tumour age is 18 month on average and bilateral involvement in its one third of cases On B-scan a retrolantel echogenic mass noted with an [8]. USG shows echogenic lesion and calcium deposits absence of any retinal tumour which is regular in shape with optic nerve involvement (Fig 2 A). Two such cases and small.persistent hyaloids vessels noted as an were noted in our study. echogenic line connecting the retrolantel mass and the Coats' disease optic nerve head (Fig 3-C). We noted one such case in 2 year old female patient. It consists of vascular anomalies within retina leading to leakage from the abnormal vessels into the subretinal Dislocated Lens in vitreous space. It occurs predominantly in young males, in the first Dislocation of lens into opaque media is a perfect decade of life. Disease is usually unilateral with male indication for ultrasound. The abnormally placed lens is predominance [9]. On b-scan the retina appears easily detected because of its shape and strong detached. Small echogenic opacities are present in reflectivity [Fig 2-D]. In our study, 3 cases of dislocated subretinal space, representing the red blood cells and the lens were found amongst 20 cases of ocular trauma. cholesterol deposits (Fig 3 D). One such case of coats disease in 11 year boy was noted in our study. Endophthalmitis CHOROIDAL PATHOLOGY Endophthalmitis as reported by Munk et al (1991) is a rare and dreaded post operative complication of eye where the Choroidal Detachment vitreous chamber is filled with low amplitude echoes [7]. Here the choroid is elevated and subchoroid space is Out of 7 cases ultrasonography detected 4 cases while 3 filled with either fluid or blood. One case was found in our cases were diagnosed as vitreous haemorrhage but study which showed two opposite echogenic convex lines follow up study revealed to be of endophthalmitis. extending into the vitreous cavity. Retinal attachment was

76 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 also associated. These echogenic lines did not involve asymmetrical with inferior rectus being the most common the optic nerve head. extraocular muscle involvement (Fig 3-A). Dysthyroid Choroidal melanoma orbitopathy, the other name, is most common cause of proptosis. There may be restriction of eye movements but They are composed of densely packed tumour cells and diplopia is rare and pain is uncommon. The disease is the overlying Bruch's membrane is intact in dome shaped bilateral with multiple muscles involvement. The inferior Choroidal melanoma.in mushroom shaped Choroidal and medical rectus muscles are most commonly involved melanoams densly packed tumour cells noted. The followed by superior rectus and lateral rectus. overlying Bruch's membrane is rupture with a collar- button appearance. On USG they appears as echogenic Lacrimal Gland Tumor subretinal mass [10]. One such case in 67 year man was Data about the prevalence of lacrimal gland tumor is quite noted in our study. USG shows well defined uniform sparse in the literature as this condition is quite rare. echotexture lesion in subretinal space. (Fig 2 B) Malignant epithelial neoplasm of the lacrimal gland SCLERAL PATHOLOGY account for approximately 2% of all orbital neoplasms. Similarly, epithelial neoplasms account for only 4% of all Posterior scleritis lacrimal gland lesions. On sonography lacrimal gland Inflammation of sclera is a painful condition. Two such tumour revealed as, a rounded, hypoechoic mass with cases of our study presented with swelling at well defined or ill-defined margin. corneoscleral junction and a convex margin inwards Metastasis which was due to localized scleritis because of foreign body incarcerated in the sclera. Extraocular orbital metastases are uncommon, accounting for 2 - 11% of all orbital neoplasms. 1 case of OPTIC DISC PATHOLOGY metastasis was noted in our study in 57 years old women Optic disc drusen with proptosis and was known to have breast carcinoma. Sonography revealed solid appearing mass with ill They are calcified nodules buried within the optic nerve defined margins in superolateral part of orbit with head. One such case was noted in our study in 66 year old calcification. woman. Sonography shows characteristically hyperechoic spots at fundus (Fig 2-C) and particularly Dermoid helpful in revealing drusen buried at optic nerve which are Dermoid and epidermoid cysts are examples of otherwise invisible on fundoscopy. choristomas, tumors that originate from aberrant EXTRAOCULAR PATHOLOGIES primordial tissue. Berges et al (1992) reported dermoid cyst the commonest developmental cyst [11]. They are Optic Nerve Tumor benign lesion occurring in the 1st decade of life. They are Optic nerve tumors include mainly glioma, meningioma located supero- laterally under the lid. Dermoids usually and neurofibroma. In our study, one case of optic nerve contain fat and may contain solid epidermoid structures. tumor was seen as a fusiform hypoechoic mass with well Some dermoid cyst contains homogeneous material defined margins encasing the optic nerve. Calcification whereas other contains layers of keratin, hair tuft, calcium was not appreciated on USG. etc. Orbital Pseudotumor Mucocele of Lacrimal Sac Orbital pseudotumor is the commonest inflammatory Mucocele of lacrimal sac is a cyst like enlargement of the lesion of orbit. The term pseudotumor means idiopathic lacrimal sac secondary to chronic dacryocystitis [12]. It orbital inflammation. Middle aged disease characterized presented with medial canthus mass lesion which could by a triad of proptosis, pain and impaired mobility. Usually be confused with granuloma or tumor of lacrimal sac. it is unilateral. It is divided into following distinct entities: 1- Mucocoele formation occurs due to nasolacrimal duct Myositis, 2- Dacryoadenitis, 3- Perineuritis, 4-Trochlear obstruction with or without canalicular obstruction. inflammation, 5- Scleritis, 6- Lymphoid hyperplasia Lid Haemangioma Myositic type was characterized by thickening of Haemangioma is a tumor of childhood that forms a soft extraocular muscles and was the commonest subtype. Perineuritic type showed inflammation of Tenon's capsule bluish mass and may involve any part of the orbit including and widening of optic nerve producing characteristic 'T' the eyelid. It has female predominance and predilection sign. This sign disappear with steroid therapy. for upper lid, presents shortly after birth. In some cases there may be intraobrital extension diagnosed on USG / Grave's Ophthalmopathy CT.[13] All of our 3 cases of grave's ophthalmopathy were

77 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 Lid Carcinoma tumors, retinal detachment, vitreous hemorrhage, foreign Lid carcinoma can arise either from epithelial elements or bodies, and vascular malformations. Ultrasonographic from adnexal component of lid with basal cell carcinoma findings were well correlated with clinical, operative & on histology. Other lesions could be sebaceous gland histological observation. Hence B-mode real time carcinoma, squamous cell carcinoma & malignant ultrasonography with high frequency probes provides melanoma. It is more common in upper eyelid. It spreads cost-effective, non-radiation, non-invasive non-ionizing via lymphatics. Vascular invasion with hematogenous technique which can be performed in outdoor patient metastasis also occur. It carries a poor prognosis in cases without any use of anesthetics or sedative therapy. with 10 mm diameter & duration of > 6 months. REFERENCES TRAUMA 1. Baum G., Greenwood I. : The application of ultrasonic locating techniques to ophthalmology.Arch. Ophthalmol. 60, 263, 1958 Ocular Trauma 2. Byrne SF, Green RL. Ultrasound of the eye and orbit, 2nd ed. Orbital trauma is classified into contusion injury, Philadelphia, PA: Mosby, 2002:544 perforating injury & foreign body. In present study, 20 3. Sen KK, Parihar JKS, Saini M, Moorthy RS. Conventional B-mode patients presented with history of trauma. Vitreous ultrasonography for evaluation of retinal disorders. MJAFI 2003; 59:310 -312 haemorrhage & retinal detachment were the commonest 4. Erickson SJ, Hendrix LE, Massaro BM, et al. Color Doppler flow findings followed by lens injury intraocular foreign body imaging of the normal and abnormal orbit. Radiology1989 ; and Pthysis bulbi. Other findings were ruptured globe, 173:511 -516 retrobulbar and soft tissue haematoma, posterior vitreous 5. Vashisht S., Berry M. : US evaluation of the eye IJRI 4 195-201, detachment, choroidal detachment, endopthalmitis. 1994. Traumatic eye may become misshapen especially in 6. Restori M., Macleod D : Ultrasound in previtrectomy assessment. chronic injury; the globe may lose volume, show scleral Trans ophthalmol soc UK 97 : 232-234, 1977 thickening and/or calcification and become deformed, 7. Munk P.L.et al : Sonography of eye .AJR 15 : 1079-1086, 1991. referred to as PTHYSIS BULBI. [7] 8. Finger PT, Khoobehi A, Ponce-Contreras MR, Rocca DD, Garcia JP Jr. Three-dimensional ultrasound of retinoblastoma: initial Intraocular Foreign Body experience. Br J Ophthalmol 2002;86 : 1136-1138 Ultrasound is useful in the localization of foreign bodies 9. Smithen LM, Brown GC, Brucker AJ, Yannuzzi LA, Klais CM, particularly metal, glass or reflective material. They are Spaide RF. Coats' disease diagnosed in adulthood. seen as small bright areas with marked reverberation Ophthalmology. 2005;112(6):1072-8. artifacts posteriorly. Two cases of foreign bodies 10. Finger PT, Romero JM, Rosen RB, et al. Three-dimensional ultrasonography of choroidal melanoma: localization of associated with vitreous haemorrhage were found here. radioactive eye plaques. Arch Ophthalmol 1998;116 : 305-312 Plain skiagram of orbit showed the presence of foreign 11. Berges O., Vignaud J., Boulin A. : The orbit : In Grainger R .G., body. Allison D. J . (eds) : The Diagnostic Radiology, An Anglo American Ruptured Globe text book of imaging. Vol.3,2099-2120,1992. 12. Mc Cord C.D. : The lacrimal drainage system. In Duane Tc (ed.) : One case of ruptured globe was found following severe Clinical Ophthalmology, 4, 1-25, 1980. blunt trauma, with distorted globe on USG. Anterior and 13. Dallow R.L. : Evaluation of unilateral exophthalmos with posterior segment could not be made out separately, lens ultrasonography. : Analysis of 258 consecutive cases. The was dislocated posteriorly. Vitreous completely filled with Laryngoscope 1905-1919, 1975 haemorrhage. Sclera was ruptured posteriorly with 14. Coleman D.J., Jack R.L., Franzen L.A. : Ultrasonography in ocular extrusion of vitreous body [14]. trauma.Am. J. Ophthamology. 75, 279, 1973 Retrobulbar haematoma One case in our present study affecting left orbit in a 12 years old male following injury had evidence of proptosis & eyelid swelling. Sonography revealed a well defined hypo-echoic mass in retrobulbar area (Fig 3-B). Optic nerve and extraocular masses were not well defined. CONCLUSION Sonography of the eye shows a variety of diseases with remarkable clarity. The technique is more cost-efficient than other diagnostic techniques and is well tolerated by the patient. High-frequency transducers make it possible to clearly show normal anatomy and pathology such as

78 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 A Study of Prevalence of Hypertension in School Children Dr Banker Chirag A*, Dr Jitesh Chavda**, Dr Khyati M. Kakkad***, Dr Panchsilla Damor**** *3rd Year Resident, **Assistant Professor, ***Associate Professor of Paediatric, ****Assistant Professor Smt Scl Gh, Ahmedabad, Gov. Medical College, Bhavnagar KEY WORDS : Prevalence, hypertension in school children

ABSTRACT : This study was conducted among 983 school children(490 boys and 393 girls) of age(5-15 years) of Ahmedabad municipal corporation schools and semi government school to find out the prevalence of hypertension in children and its correlation with age, gender, height ,and weight of children. In this study mean systolic blood pressure and mean diastolic blood pressure increase with age from 5+ to 12+ year of age. In our study there was no significant difference in mean SBP and mean DBP among boys and girls. It resulted 3.19% of total prevalence of high blood pressure, among which 3.22% was in boys and 3.16% in girls. Highest prevalence of high BP was observed at 12 year of age with prevalence of 10.71% in boys and 5.26%in girls. Alone isolated systolic HBP was found out to be 75.75%, isolated diastolic HBP was not found in any case where as both high SBP and high DBP were found in 24.25% of cases. All children were in pre-hypertension stage, and HBP was directly proportional to increased age, weight, height, and BMI of a child.

INTRODUCTION target organ damage, diabetes, or persistent Systemic hypertension has been considered to be hypertension despite nonpharmacologicmeasures associated with adult population. But off late increase should be treated with antihypertensive medications. numbers of children are also being affected. Childhood Thiazide diuretics, angiotensin-converting enzyme hypertension is an established predictor of adult inhibitors, angiotensin II receptor blockers, beta blockers, and calcium channel blockers are safe, effective, and well hypertension and organ damage, and it is underestimated 12 problem in developing countries.An increasing number of tolerated in children . healthy children and adolescents across the world are We present here, an attempt to find out prevalence of being diagnosed with HTN21 . Normal blood pressure HTN in children of 5- 15 years of AMC school and semi values for children and adolescents are based on age, government school in respect of their age, sex, height . gender, and height, and are available in standardized MATERIAL AND METHODS tables. Primary HTN, once considered a rare occurrence in pediatric patients, is seen more often particularly in While conducting this prospective study, schools were obese patients .other factors responsible for increased randomly selected after prior permission and consent prevalence of hypertension in children include life style from the concerned authorities.Samples were selected by changes such as decrease physical activity, increased random sampling method. Total 983 students of 5-15 intake of high calories, high sodium and low potassium years of age were examined.The age was determined foods, use of caffeinated and alcohol beverages, from birthdate of school registration record. Blood smoking, mental stress and sleep deprivation14 . A pressure and anthropometric data was collected. BMI secondary etiology of hypertension is much more likely in was calculated by the formula BMI=weight(kg)/height children than in adults, with renal parenchymal disease (m2). BP was measured using standardized and renovascular disease being the most common. sphygmomanometer with appropriate size cuff covering Children with hypertension should also be screened for two third of the arm. The BP was measured with child in a other risk factors for cardiovascular disease, including sitting position, with arm at the level of heart and after a 22 diabetes mellitus and hyperlipidemia, and should be five minute rest . If the SBP and / or DBP were in higher evaluated for target organ damage with a retinal range of blood pressure than2 additional readings were examination, for renal damage and echocardiography. obtained at an interval of 1-3 weeks. The lowest of these Hypertension in children is treated with lifestyle changes, reading was recorded. Those children who had recorded including weight loss for those who are overweight or high blood pressure were advised to come at our obese; a healthy, low-sodium diet; regular physical institution for further evaluation. In our study to identify BP activity; and avoidance of tobacco and alcohol. Children percentiles, first step is to refer to height percentile table with symptomatic hypertension, secondary hypertension, and see which percentile of height child has. Then, refer Correspondence Address : Dr. Banker Chirag A. 1176, Shivam Society, Sector-27, Near ASP Office, Gandhinagar-382028.

GMJ 79 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 the values in BP percentile table corresponding to the year of age 5.26% was found. The reason why there was child's sex,age, and height percentile. Then according to such high prevalence in adolescent age not known but it value in the table and child measurement, child was may be duo to some life style modification. classified according to it into specific category. Actual BP Among them 25 student had isolated high SBP and 8 percentiles assume clinical significance in diagnosis, student had both high SBP and high DBP. None of them classification and treatment targets of HTN in children. had isolated high DBP which also comparable to other Systolic or diastolic BP equal to 95th percentile for gender, study.24 All student with high BP was had pre HT. among age, and height for 3 or more occasions is defined as boys it was 20/490 had pre HT and in girls 12/390 had pre hypertension in children. Pre-HTN is defined as systolic HT. During study there were 13 students had high BP BP or diastolic BP that are equal to 90th percentile but <95 th recorded on first visit but on 3 successive visits they had percentile. Stages 1 hypertension refers to BP from 95th normal BP so they not included in prevalence rate. th percentile to the 99 percentile plus 5 mm hg. Stage 2 HTN HTN is a major risk factor for cardiovascular and 19 th refers to values above stage 1 HTN . The 50 percentile cerebrovascular diseases. Studies indicate that BP of BP is the target attempted when hypertensive children increases with age7,8,9,10 . Population base epidemiological are subjected to antihypertensive drug therapy. studies show that primary HT is far more common among RESULT AND DISCUSSION apparently healthy children.Although the prevalence of HTN is far less in children than in adults, there is enough In our study we include 983 students of 5-15 years of age evidence to suggest that the roots of essential HT extend from different schools, among which 490 were boys and into childhood17,18 . 393 were girls.As shown in table 1 there was increase in mean SBP and mean DBP with age up to 15+ year of age. In the present study, shows that SBP and DBP have a In girls mean SBP increase with age up to 12+ years and positive correlation with age, height, weight, and BMI mean DBP increase with age up to 11+ years of age with which is consistent with the previously reported studies on exception at 10+ years of age. There was no statistically BP in children17 . In our study a significant correlation of difference in mean SBP and mean DBP among boys and height was found with SBP as well as DBP, whereas girls which also observed in other study2,3,23 . Such SARIN ET AL17 reported a significant correlation between increase in mean BP due to increase in age may be due to BP and weight. And VOORS ET AL23 , reported that BP increase in body mass. As shown in table 2 there were 32 correlates more closely to height and body mass than students having high BP, high prevalence with 10.71% age. An increase in SBP and DBP with age has also been prevalence at the age of 12+ in boys and in girls at 12+ reported in Indian children by other authors1, 6, 20 .

TABLE 1 : Mean SBP and DBP in boys and girls according to age and increment in it.

Systolic BP Diastolic BP Age (in BOYS GIRLSBOYS GIRLS years) Mean Increment Mean Increment Mean Increment Mean Increment 5+ 84.60 86.47 52.44 53.89 6+ 87.88 3.28 88.52 2.05 55.52 3.08 54.52 0.63 7+ 87.87 -0.01 89.75 1.23 56.20 0.68 56.75 2.23 8+ 91.41 3.54 90.36 0.81 59.00 2.87 60.73 3.98 9+ 91.53 0.12 92.57 2.01 59.28 0.21 62.23 1.50 10+ 97.44 5.91 95.78 3.21 61.56 2.28 62.18 -0.05 11+ 98.70 1.26 104.00 8.22 64.32 2.76 68.05 5.87 12+ 104.20 5.5 104.05 0.05 65.61 1.29 65.29 -2.76 13+ 97.18 -6.62 103.77 -0.28 62.30 -3.31 63.44 -1.85 14+ 103.55 5.57 107.35 3.58 62.73 0.43 65.27 1.93 15+ 100.46 -3.09 109.91 2.56 57.24 -5.48 64.00 -1.27

80 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 TABLE 2 : Prevalence of HBP IN boys and girls in different age group

Boys Girls No of Student No of Student Age Percentage Percentage Student having HT Student having HT 5+ 50 1 2% 19 1 5.2% 6+ 33 1 5.03% 23 1 4.34% 7+ 15 0 0 18 0 0 8+ 41 2 4.87% 22 1 4.54% 9+ 53 1 1.88% 35 0 0 10+ 88 2 2.27% 65 1 1.53% 11+ 50 1 2% 37 1 2.70% 12+ 56 6 10.71% 38 2 5.26% 13+ 53 2 3.77% 43 2 4.65% 14+ 97 3 3.09% 49 1 2.04% 15+ 54 1 1.85% 44 2 4.14% 3.22% 3.16% SUMMARY AND CONCLUSION 7. Forfar and arneil's text book of paediatric, 7th edition, cardiovascular disease chapter. The prevalence of high BP in school going children of 5-15 8. Ganong's review of medical physiology,23rd edition section vi : years of age was 3.19 % (32/983). The prevalence in boys cardiovascular physiology was 3.22 % (20/490) and in girls was 3.16 % (12/393). All 9. Ghai's textbook of pediatric , 7th edition, cardiovascular disease children having high BP were in pre hypertension stage. chapter Among children having high BP, 75.75 % (25/32) had 10. Gupta AK, Ahmed AJ. Normal blood pressure and the evaluation isolated systolic high BP and 24.25 % (8/32) had both high of sustained blood pressure elevation in childhood. Indian pediatr 1990 ; 27 :33- 42 SBP and DBP. Isolated high DBP was not found in any of th 11. Guyton Textbook of Medical physiology 11 edition. the children. There was no positive correlation of mean 12. K.D. Tripathi's text book of pharmacology, antihypertensive drug SBP and mean DBP among boys and girls. Age, height, chapter. weight, and BMI were positively correlated with both SBP 13. Lauer RM, Burns TL,Clarck WR. Assessing children's blood and DBP.Prevalence of overweight was 2.03 % and there pressure consideration of age and body size : The Muscatine was no positive correlation between high BP and study . paediatric 1985 ; 75 : 1081-90. overweight. 14. Mitsnefes MM . Hypertension in children and adolescent. Pediatr Clin NorthAm 2006 : 53 :493-512. As there is enough evidence to suggest that roots of 15. Nelson's textbook of paediatric, 18th edition, cardiovascular essential HT extend into childhood, this emphasize disease chapter. routine screening particularly in adolescent age group to 16. Original article :Year : 2008 , Volume : 1 , issue : 2, page :101-106, detect HT timely as in present scenario where risk factor Distribution of blood pressure in school going children in rural area of wardha district , maharashatra, india . for HT in the childhood like change in physical activity 17. Sarin D., Chaturvedi P. Normal blood pressure and prevalence of pattern,obesity, high calorie intake, use of caffeinated and hypertension in school going children. J MGIMS 1997;1:32-5 alcohol beverages, smoking, mental stress etc. are 18. Sharma BK, Sagar S, wahi PL, Talwar KK, Singh S, Kumar L. present. blood ptrssure in school children in North-West India. Am J REFERENCES epidemiology1991; 134:1417-26 19. The fourth Report on the diagnosis, Evaluation, and Treatment of 1. Aggarwal ,V.K., Sharan R. Srivastava,A.K. Kumar, P.and Pandey, C.M.:Blood pressure profile in children of age 3-15 years. Ind. high blood pressure in children and adolescent,2004 American Pediatr., 20: 921-925 (1983) heart association, inc, Bonita Falkner ; Stephen R. Daniels 2. Anand NK ,Tandon, Biophysical profile of blood pressure. Indian 20. Verma M, Chhatwal J, George SM. Obesity and hypertension in pediatr 1996;33: 337-81. children. Indian Paediatr 1994; 31: 1065-9; biophysical profile of 3. Anand NK ,Tandon, prevalence of hypertension in school going blood pressure in school children. Indian Pediatr 1995; 32:749-54. children.Indian pediatr 1996;33: 337-81. 21. Indian Pediatr 2010;47: 473-474, Hypertension in pediatric 4. Blood pressure from Wikipedia, the free encyclopedia patients by Tej K Matto 5. Chadha, S.L., Tandon, R., Shekhavat, S. and Gopinath.N,. An 22. Pickering et al. 2005,p 146. See blood pressure measurement epidemiological study of blood pressure in school children (5-14 method. years) in Delhi. ind. Heart journal ., 51: 178-182 (1999) 23. VoorsAW ,webber LS, FreichsRR.Body height and body mass as 6. Chahar CK,Shekhavat V,Miglani N, Gupta BD . A study of blood determinants of basal blood pressure in children : The Bogalusa pressure in school children at Bikaner. Indian J Pediatr 1982 ; 49: Heart Study .Am J Epidemiol 1977; 106:101-8. 791-4

81 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12

Study of Incidence of Helicobacter Organisms in Cases of Gastritis. Dr. Moxda S. Patel*, Dr. Alpa A. Shah**, Dr. Himanshu P. Patel***, Dr. Deepak S. Joshi **** *Assistant Professor, **Associate Professor,***3rd year Resident, **** Professor & HOD. AMC MET Medical College, Maninagar, Ahmedabad – 8. KEY WORDS : Helicobacter Pylori, Gastritis

ABSTRACT Helicobacter is a gram negative curved rod. Helicobacter was previously termed as campylobacter. Since the bacteria were initially found only in the region of the pyloric part of the stomach, they received the spices name “pyloridlis” which was later changed to the grammatically correct form “pylori” (menge et al,1987).2 H. Pylori plays a pathogenic role in the aetiology of gastritis rather than colonizing an already inflamed gastric mucosa. H. Pylori only colonizes gastric type, it is not found colonizing intestinal type mucosa in the stomach susceptible animal models inoculated with a suspension of H. Pylori have developed histologically proven gastritis. 4 There are mainly two major forms of gastritis. Type A gastritis, which involves the fundus is associated with pernicious anaemia and Type B gastritis, for which mainly the H. pylori is the aetiological agent.3,4,5 Total 50 cases were studied during three years at L. G. Hospital. Majority of the symptomatic cases were in the age group of 31 – 40 years. However the incidence of H. Pylori was found to be highest in the 41 – 50 years of age group. Helicobacter Pylori infection is frequently associated with antral gastritis. The incidence of Helicobacter pylori is found to be highest in cases of histologically diagnosed chronic diffuse gastritis. The incidence of H. Pylori infection is found to be more common with moderate degree of gastritis. The male sex is associated with both a higher incidence of gastritis as well as H. Pylori Infection. Symptomatic cases normal on endoscopy may show chronic gastritis histologically. Serology is more sensitive and specific than urease and histological confirmation for H. Pylori infection. This obviates the necessity of a gastric biopsy and serology for H. Pylori IgG antibody in all patients with upper gastrointestinal tract symptoms.

INTRODUCTION There are mainly two major forms of gastritis. Type A Helicobacter is a gram negative curved rod, or also U- gastritis, which involves the fundus is associated with pernicious anaemia and Type B gastritis, for which mainly shaped coccoid, measuring about 1.5-5μm in length and 3,4,5 0.3-0.5 μm in diameter, having 4-6 unipolar, polytrichous the H. pylori is the aetiological agent. flagella with rounded thickening at the distal end. 1.2 MATERIAL AND METHODS Helicobacter was previously termed as campylobacter. In The present study consist of the bio-chemical and 1983 warren and marshal have showen that the histopathological interpretation of gastric biopsy for inflammatory activity of gastritis is significantly correlated helicobacter organisms. Serological confirmation of with a characteristic type of stomach specific bacterium helicobacter IgG antibodies is also done in my study. a (marshall at 1985 morris and nicholson,1987) they total number of 50 cases were reviewed during the course cultivate the bacteria from biopsy material and classified of this present study and findings in each case were the micro-organisms to the genus campylobacter. Since collected . the bacteria were initially found only in the region of the As H. Pylori have been reported to be most numerous in pyloric part of the stomach, they received the spices name the gastric antrum6, the site of biopsy in all cases was the “pyloriclis” which waslater changed to the grammatically pyloric antrum. correct form “pylori” (menge et al,1987). 2 All patients studied come to the outpatient department H. Pylori plays a pathogenic role in the aetiology of with upper gastrointestinal complaints of dyspepsia, gastritis rather than colonizing an already inflamed gastric vomiting, epigastric, heat barn etc. routine investigation mucosa. H. Pylori only colonizes gastric type, it is not were carried out and ultrasonography and barium meal found colonizing intestinal type mucosa in the stomach examination were done wherever necessary. susceptible animal models inoculated with a suspension of H. Pylori have developed histologically proven gastritis. Atotal of four gastric biopsies were taken from within a few 4 Correspondence Address : Dr. Mixda S. Patel 4 B SevaKunj Society, Near Prashant Park, Fatehpura, Paldi. Email : [email protected]

GMJ 91 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 centimetre of each other. Two biopsies were taken in normal saline for the urease test and two biopsies in buffered formation for histopathology examination.17 The urease test employed by L.G. laboratory consists of immediate incubation of the two gastric biopsies together in a home made buffered urea phenol red agar gel. The biopsies were inoculated and incubated at 37 °c. At the end of one hour, a change in colour of the media from yellow to pink was considered as positive.

Serological testing is generally accepted as a valid, non- invasive screening method for the detection of H. Pylori infection5 Together with standard prenatal screening and blood analysis, one ml venous blood was taken for serology. The sera were tested using the Immunocomb® II Helicobacter Pylori IgG test, an indirect solid phase EIA 11

At the outset of the test, serum or plasma specimens are prediluted 1:11 and added to the diluent in the wells of row-A of the developing plate. The comb is then inserted in the wells of row A. Antibodies to H. Pylori, if present in the specimens, will specifically bind to the H. Pylori antigens on the lower spot on the teeth of the comb. After noting the result the biopsy material from positive Simultaneously immunoglobulin's present in the cases were retrieved. From the tube and two squash specimens will be captured by the antihuman smears were prepared, fixed and stained with Gram's immunoglobulin on the upper spot (Internal Control). stain. Smears positive for bacteria were noted as gram Unbound components are washed away in row B. In row negative, spiral organisms. 8.10 C the anti H. Pylori IgG captured on the teeth will react The other two biopsies were processed for with anti human IgG labelled with alkaline phosphatase. histopathological examination, they were processed for In the next two rows unbound components are removed paraffin section and stained with Haematoxylin and Eosin by washing. In row – F, the bound alkaline phosphatase and sections were then studied to note the various react with chromogenic components. The results are changes in the mucosa. Each biopsy specimen was assessed for the presence of acute superficial gastritis visible as gray-blue spots on the surface of the teeth of the (acute inflammatory changes involving pits and surface comb. epithelium) and chronic gastritis (chronic inflammatory changes involving glandular compartment). The gastritis was further graded as either mild, moderate or severe (mild = superficial inflammation with less than 25% pits involved; moderate = superficial inflammation involving 25 % to 50 % of pits with or without deep inflammation, sever = superficial inflammation involving more than 50 % of pits with deep inflammation and / or pit abscesses.) 7 The other stains were Giemsa and Carbol-fuschin (Giemnez stain). H. Pylori is seen as spiral, bright red organism overlying the surface epithelium in the pits.

92 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 The kit includes a positive control and a negative control. The upper spot should also appear on all other teeth to At the end of the test the positive control should show two confirm that the specimen was added. gray-blue spots and the negative control should show the OBSERVATIONS & RESULT upper spot and either no other spots or faint lower spot. Number of cases studied : 50 The result of the present study are listed below

Table – 1 Correlation between Age, Histologically present Gastritis and Helicobacter Pylori

Age Group No. of % of cases Gastritis H. Pylori in years casesMild Moderate Positive 11-20 03 06% 66.7% 33.3% 33.3% 21-30 10 20% 60% 40% 40% 31-40 20 40% 55% 45% 65% 41-50 11 22% -- 100% 100% 51-60 04 08% 50% 50% 75% 61-70 02 04% 50% 50% 50%

The above table indicates that majority of the This study Men dominated in both, sex -32 cases (64%) symptomatic cases (40%) were in the age group of 31-40 and positivity for H. Pylori infection (60.6%). years. However the incidence of H. Pylori was found to be highest in the 41-50 years age groups (100 %) though they form only 22% of total number of cases. The incidence of mild changes of gastritis is highest in the 11-20 years age group (66.7 %) while that of moderate gastritis is highest in the 41-50 years age group (100%).

Table – 2 Sex in relation to H. Pylori infection Total No. H. Pylori H. Pylori Positive (33) Negative (17) Male Female Male Female 50 cases 20 13 12 05 Of the total number of cases 66% of them were 60.6 % 39.4 % 70.6 % 29.4 % associated with H. Pylori infection.

93 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 Table – 4 Correlation of HLO with presence of Table – 7 Histological Diagnosis of total histologically diagnosed gastritis. cases studied. Helicobacter Gastritis No. Histological Diagnosis No. of % of Cases cases Mild Moderate 1 Chronic Superficial Gastritis 26 52 % H. Pylori Positive 12(36.4%) 21 (63.3%) 2 Chronic Diffuse Gastritis 15 30 % H. Pylori Negative 10 (58.8%) 7 (41.2%) 3 Chronic Atrophic Gastritis 06 12 % H. Pylori infection was more common with moderate 4 Chronic Active Gastritis 03 06 % degree of gastritis (63.3%) as compared to mild gastritis. The next common lesion found on histological Table – 5 Association of H. Pylori and interpretation was chronic superficial gastritis (52%) Endoscopic Diagnosis. Table – 8 Correlation between Histological Endoscopic H. Pylori H. Pylori Total Diagnosis and H. Pylori Gastritis Positive Negative cases No. Histological No. of H. Pylori Positive Normal Mucosa 11 (64.7%) 6(35.3%) 17(34%) Diagnosis Cases No. of % of Acute Gastritis 6(75%) 2(25%) 08(16%) cases cases Chronic Gastritis 16(64%) 9(36%) 25(50%) 1 Chronic Superficial 26 15 57.7 % Gastritis 2 Chronic Diffuse 15 12 80 % Gastritis 3 Chronic Atrophic 06 04 66.7 % Gastritis 4 Chronic Active 03 02 66.7 % Gastritis

Normal appearance of mucosa on endoscopic examination were positive for H. Pylori infection in about 64.7% cases.

Table – 6 Association of Histological gastritis and endoscopic diagnosis. The incidence of Helicobacter pylori was found to be highest (80%) in cases of histologically diagnosed chronic Endoscopic Histological Diagnosis diffuse gastritis. Diagnosis Chronic Chronic Chronic Chronic Table 9 – Comparative study between Biochemical, Superficial Diffuse Atrophic Active Histological and serological examination for H. Pylori Gastritis GastritisGastritis Gastritis Type of H.Pylori H.Pylori % of Normal 9(52.9%) 7(41.2%) 1(5.9%) - Examination Positive Negaive Positive Mucosa Cases Cases Cases Biochemica29 21 58% l Acute 2(25%) 3(37.5%) 1(12.5%) 2(%) Examination of Gastritis organisms Chronic 15(60%) 5(20%) 4(16%) 1(%) (Urease test) Gastritis Histological 25 25 50% examination of None of the cases with a normal appearance on organisms by endoscopy were associated with a normal histology. 52.9 (Giemnez Stain) % of the cases with a normal endoscopic diagnosis were Serological 33 17 66% associated with chronic superficial gastritis histologically. Examination for (H. Pylori IgG Ab)

94 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 No. Study group No. of H. Pylori cases positive 1 Warren and marshall - About-50% 198312 2 Fiocca R et al13 310 230(74.5%) 3 Lambent et at14 82 50(61%) 4 TAYLOR ET AL15 51 22(43%) 5 Naseer Ahmed et al10 150 99(66%) 6 Bleker et al5 542 120(22.1%) (study in asymptomatic subject) 7 Menelall et al5 - 66.7% 8 Present study 1996 50 33(66%) From above study, it can be indicated that serology is more sensitive and confirmative as compare to bio- In the present study 66% of the 50 cases studied were chemical and histological examination for H. Pylori positive for H. Pylori infection. infection. H. pylori was detected in 63.6% of cases with changes of DISCUSSION moderate gastritis histologically. The present study was carried out on out patients Warren and marshall2,10 in 1983 showed that the attending the surgical outpatient department. All of them organisms were always seen with active chronic-gastritis, had symptoms pertaining to the upper gastrointestinal were fewer in number chronic gastritis and were tract. consistently observed in the gastric antrum. Atotal number of four biopsies were taken from the pyloric Bleker et al5 showed that the serology is a valid non- antrum within a few centimetres of each other. This was found to be sufficient for an accurate diagnosis of various invasive screening method for the detection of a H-pylori histological types of gastritis. infection. It is improvement for screening of asymptomatic In present study it was noted that incidence of gastritis subject. increases with age. The younger patients shows mild Rollason et at16 in a retrospective study described H. changes of gastritis histologically. The middle aged group Pylori in association with chronic superficial and chronic were associated with H. Pylori infection and moderate atrophic gastritis. gastritis on histology. This probably indicates the progress from mild to moderate gastritis with an increase The correlation between the endoscopic diagnosis, in age. histological appearance and H. Pylori infection is very In present study, 64% of all cases were male and 60.6% poor. About 34 % of cases with normal endoscopic of all patients positive for H. Pylori were also male. findings were associated with histological changes of gastritis out of which 64.7% cases were H. Pylori positive. Naseer ahmed et al (1991)10 showed that men The relation between chronic gastritis and H. Pylori can predominated their study of 150 cases both in sex (86%) 17 and positive for H. Pylori (87.9%) be seen in the following table.

The incidence of H. Pylori with active gastritis is about 66.7 % though the prevalence of active gastritis is low. Mc Nulty et al3 found that the H. Pylori playas a pathogenic role in the aetiology of gastritis rather than colonizing an already inflamed gastric mucosa. H. Pylori only colonizes gastric type mucosa.

95 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 CONCLUSION 5. Uwe Blecker;M.D.;Sophie Lancies M.D. Et Al, Serology As A Valid Screening Test. For Helicobacter Pylori Infection in Helicobacter Pylori infection is frequently associated with Asymptomatic Subjects.Arch Patho Lab Med Vol 119. Jan 1995 antral gastritis 6. J. J. Wyatt And S.F. Gray Detection Of Campylobacter Pylori By The incidence of Helicobacter pylori is found to be highest Histology, Campylobacter P.64 in cases of histologically diagnosed chronic diffuse 7. Rober M. Strauss. M.D.D Timothy C. Wang Et Al. Association of H. Pylori Infection with Dyspeptic Symptoms In Patient gastritis. Undergoing Gastroduodenoscopy. A.J.M. Vol 89, 1990 Oct The incidence of H. Pylori infection is found to be more 8. Cliodna A.M. Mcnulty; Julie C. Dent. T.S. Uff, M.W. Gear and common with moderate degree of gastritis S.P. Wilkinson. Detection Of Campylobacter Pylori By Biopsy, Urease Test; An Assessment In 1445 Patient, Gut, The prevalence of H. Pylori infection is found to be the 1989;30;1058;1062 highest in the age group of 41 – 50 years. Majority of 9. M. Deltenre, V. Glupenzynski, C. Deprez, J.E. Nyst Et Al. The cases associated with histologically present gastritis are Reliability Of Urease Test,HistologyAnd Culture In Diagnosis Of in the age group of 31 -40 years. Campylobacter Pylori Infection. Dept of Gastroenterology; Microbiology And Pathology University, Hospital Brugmann The male sex is associated with both a higher incidence of Belgium. gastritis as well as H. Pylori Infection. 10. Naseer Ahmed, P.R.Mlur, M.N. Sankapal and S.J. Nargotimath. Prevalence of Campylobacter Pylori In Non-Ulcerative Symptomatic cases normal on endoscopy may show Dyspepsia. I.J.P.M.34; 4; 247; 52;1991. chronic gastritis histologically. 11. Organics ; Immunocomb' Helicobacter Pylori Igg Serology is more sensitive and specific than urease and 12. Warren Jr Marshall B; Unidentified Curved Bacilli On Gastric histological confirmation for H. Pylori infection. Epithelium InActive Chronic Gastritis Lancet 1; 1273-75; 1983. This obviates the necessity of a gastric biopsy and 13. R. Fiocca; L Villain; F. Turpini, R. Turpini. F. Solcia. High Incidence Of Campylobacter Like Organisms In Endoscopic serology for H. Pylori IgG antibody in all patients with Biopsies From Patients With Gastritis With Or Without Peptic upper gastrointestinal tract symptoms. Ulcer. Digestion;38; 234.44 1987 REFERENCES 14. J.R. Lamber, K. Dunn, M. Borromo. M.G. Korman and J. Hansky. Mouash University Department Tof Medicine and 1. David Green Wood, Richard C.B. Skick, John Forest Peutterer, Department Of Gastroenterology. Prince Henry's Hospital, Compylobater Morphology; Medical Microbiology , Vol 14; 353 Melbourn, Australia. Campylobacter Pylori. A Role in Non Ulcer 2. Varelisa, H. Pylori Antibodies, Elias, Entrickulngslabor For Dyspepsia. Immunoassays 15. Diane E. Taylor, Phd, James A Hargreaves, Laiking Ng Nsc, 3. C.A.Am. Mc Nulty, Public Health Laboratory, Glouce Streshine Richer W. Sherbamink M.D. And Kurance D. Jewell M.D.; Rouyal Hospital, Gloucester, England, Pathogenicity of Isolation And Characterisation Of Campylobacter Pyloridis Campylobacter Pylori.AComparative Factors In Gastritis From Gastric Biopsies,A.J.C.P.January 1992 4. Linda M. Besti Sander, I.O. Veldayzen, Vonzonten, Philip 16. Rollason T.P. Stone J and Rhodes J.M. Spiral Organisms In Sherman and Gregory S Benzanson, Serological Detection of Endoscopic Biopsies Of Human Stomach. J . Clinicl. Path 1984; H. Pylori Antibodies In Children And Their Parent. Journal of 27; 23-6 Clinical Microbiology, May 1994; P.1193 – 96. 17. M.F. Bdixon' Campylobacter Pylori And Chronic Gastritis, Campylobacter 14 ; 108

96 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 Study of Incidence of Congenital Anomalies In New Borns Dr. Kanan Shah*** , Dr. C.A.Pensi *Associate Professor, Department of Anatomy, Smt.N.H.L.Municipal Medical College, Ahmedabad. **Professor & Head, Department of Anatomy, B.J.Medical College, Ahmedabad. KEY WORDS : Congenital malformation, anomalies

Abstracts: In this study, all the newborns delivered at obstetrics dept. of civil hospital were examined for congenital malformations over a period of nine months. Purpose of study is to find out the overall incidence of clinically detectable congenital anomalies in newborns in hospital deliveries. Four thousand four hundred and fifty six newborn babies of consecutive deliveries were examined at birth for the presence of congenital malformations. The overall incidence of malformations was 2.38%. Neural tube defects were commonly found. The incidence of congenital malformations was higher in still born, low birth weight, male and preterm babies. Also we know immediate outcome in live born malformed babies for study of prognosis of various malformations.

INTRODUCTION

In a developing country like India due to high incidence of 2) The incidence of different congenital anomalies. infectious diseases, nutritional disorders and social stress, the developmental defects are often 3) Immediate outcome in live born malformed babies. overshadowed, but the present scenario is changing MATERIAL AND METHODS rapidly. A recent study shows that congenital anomalies It's an observational analytical cross sectional type of contribute to 9% of perinatal deaths as compared to 8% a study. decade ago. About 2% newborn infants have major anomalies. The incidence is as high as 5% if one includes Four thousand four hundred and fifty six newborn babies anomalies detected later in childhood such as of consecutive new born babies delivered at the abnormalities of heart, kidney, lungs and spine. Department of Obstetrics and Gynecology, Civil hospital, Anomalies are more common among spontaneous Ahmedabad were examined at birth for the presence of abortuses. Many anomalies are severe and cause congenital malformations. They were examined soon abortion. after birth for major and/or minor congenital malformations. Baby's gestational age, birth weight, sex Congenital anomalies represent defective and symptoms in postnatal period were noted. The morphogenesis during early fetal life. A broader definition detailed general and systemic examinations of the babies includes metabolic or microscopic defects at a cellular were carried out. As per the proforma made, complete level. medical, family, antenatal and personal history has taken Major anomalies have serious medical, surgical and .Thorough physical examinations of newborn babies cosmetic consequences. were done. High risk newborns were examined in detail In this study we have calculated overall incidence of within 12 hrs.of birth. congenital anomalies both in live born and stillborn Immediate outcome of all malformed babies were babies. recorded during the period of the mother's hospital stay. AIMS AND OBJECTIVE OBSERVATIONS Tostudy prospectively A total of 4456 consecutive births were studied for 1) The overall incidence of clinically detectable congenital malformation. There were 106 malformed congenital anomalies in newborns in hospital babies found. The overall incidence of congenital deliveries. malformations was found to be 2.38% as shown in table I.

Correspondence Address : Dr. Kanan Shah 13, Mewawalanagar society, Nr.Kiranpark, New Vadaj, Ahmedabad- 380013

GMJ 97 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 TABLE –I INCIDENCE OF ANOMALIES

Total No. of deliveries 4414 Total No. of twin deliveries 40 Total No. of triplet deliveries 1 Total No. of babies born 4456 Total No. of malformed babies 106 Incidence of anomalies 2.38% Incidence of twin deliveries was 0.9%.

Congenital malformations of the central nervous system were the highest followed by musculoskeletal system, gastrointestinal system, cardiovascular system, Genitourinary system, respiratory system, chromosomal and ear as shown in TableII.

TABLE—II SHOWING INCIDENCE OF SYSTEMWISE ANOMALIES

Table III SEXUAL VARIATION IN INCIDENCE OF ANOMALIES

Incidence of malformations in general was found to be apparently more in male (2.43%) than in female (2.20%)

DISCUSSION al(1985)4 1.5%,Graham(1988) 2%,Mishra PC & Baveja In present study, attempts have been made to find out the R(1989)78 1.46%,Mohanty et al(1989) 1.61%,Verma IC et total and individual incidence of anomalies in hospital al(1991)11 3.6% and GuhaAK(1995) 6 2%. deliveries. The overall incidence of congenital malformations was 2.38% in present study. Compares The relative difference in the occurrence of various well with the observations of Marden et al(1964)1 2-4%, malformations might be due to geographic and racial Goravalingappa &Nashi(1979)5 3.13%,Ghose et differences. The true incidence of congenital anomalies

98 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 depend upon several factors and therefore two studies Incidence of congenital malformed babies appears more are never strictly comparable. now days as compared to past because of advanced In present study Congenital malformations of the central diagnostic facilities and availability of neonatal intensive nervous system were the highest(10.42/1000) followed care unit which leads to increase chances of survival of by malformations of the musculoskeletal malformed babies. system(2.95/1000), malformations of the gastrointestinal REFERENCES system(2.49/1000), malformations of the cardiovascular 1. Clark R.D.and Eteson D.J.; congenitalAnomalies, p.159 system(2.27/1000), malformations of the genitourinary rd system(0.91/1000), malformations of the respiratory 2. Dutta;TextBook of obstetrics, 3 edition ,1994 system(0.91/1000), malformations of the chromosomal 3. Dutta A.K.;Principal of gen. Anatomy and Human th and ear(0.45/1000). genetics, 4 Edition September, 1997, p.175 Goravalingappa &Nashi(1979)56 and Guha AK(1995) 4. Ghosh S. ,Bhargava SK, Bhtani R;congenital anomalies also found high incidence of central nervous system in longitudinally studied birth cohort in a urban community. Indian j. Med. Res. Nov. 1985, 82:427 malformations. While Mishra PC & Baveja R(1989)7 found high incidence of multiple congenital anomalies. 5. Goravalingappa JP, Nashi HK; Congenital Anomalies in a Ghose et al(1985)48 and Mohanty et al(1989) found study of 2398 consecutive births.Indian Journal of medical research,Jan,1979,69:140 higher incidence of musculoskeletal system malformations. 6. Guha DK; Neonatology First Edition, 1995, p466 In present study, it was found that incidence of congenital 7. Mishra PC,Baveja R; Congenital anomalies in New borns – A Prospective study .Indian Pediatrics, anomalies was high in babies with birth weight less than Jan.1989.vol.26. 1.5 kg. Mohanty et al84 and Ghose et al also reported the same. 8. Mohanty C, et.al; Congenital Anomalies in new born A study of 10,874 consecutive birth.J. Anatomical Society of In present study it was found that incidence of congenital India.!989, vol 38 No.2. anomalies was much higher in preterm babies as 9. Nelson; TextBook of Pediatrics. compared to full term babies. Goravalingappa 5 10. Schaffer AJ; Causes of abnormalities in the new born – &Nashi(1979) also reported the same. nd Diseases of the new born, 2 edition, p36, 4th edition, In present study it was found that incidence of congenital p.71 anomalies was high in male babies. Ratio of malformed 11. Verma IC et.al; Clinical & Genetics aspects of anomalies male to female babies was found 0.58:0.41. Mohanty et of CNS.All India Institute og Med. Science,1976,1:64 al(1989)8 reported higher incidence of congenital malformations in male babies(1.91%) than in female babies(1.27%)

99 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 RESEARCH ARTICLE Study of Feto-Maternal outcome of Teenage Pregnancy at Tertiary Care Hospital Dr Rajal V Thaker*, Dr Mian V Panchal**, Dr Rupa C Vyas***, Dr Sapana R Shah*, Dr Parul T Shah****, Dr Kruti J Deliwala*** * Associate Professor, ** 2nd year Resident, *** Assistant Professor, **** Professor , Department of Obstetrics & Gynecology, Smt N H L Municipal Medical College, Sheth V S General and Sheth Chinai Maternity Hospital, Ahmedabad 380006, India

KEY WORDS : Pregnancy in Adolescent, Adolescent Pregnancy, Teenage Pregnancy

Abstract Objective: Tostudy of Feto-Maternal outcome ofAdolescent Pregnancy Study Design: Retrospective Observational Study Duration of Study: One year: September 2011 toAugust 2012 Patients and Methods: Data was collected from the case papers of the pregnant adolescents and their feto- maternal outcome was studied. Results: 5851 pregnant patients were admitted for delivery and abortion related care. Out of this, pregnant adolescents were 303. Proportion of adolescent pregnancy was 5.1%. 299 (98.6%) were married, while 4 (1.3%) were unmarried. 298 (98.3%) were above 18 years of age. 48 (15.8%) were illiterate and only 3(0.9%) studied up to higher secondary. Primi, second and third gravida were 270 (89.1%), 27 (8.9%) and 6 (1.9%) respectively. 15 (4.9%) couples ever used some method of contraception. 172(56.7%) of pregnant adolescents had anaemia. Pre term labour occurred in 54 (17.8%). Pregnancy Induced Hypertension and Eclampsia occurred in 21 (6.9%) and 9 (2.9%) respectively. 1(0.3%) of pregnant adolescent girl was infected with Human Immunodeficiency Virus. First and second trimester Reproductive loss was 9 (3%). There were 294(97%) deliveries. Vaginal delivery occurred in 199 (65.6%). 95 (31.3%) had Lower Segment Caesarean Section. Still Births were 28 (9.4%). Low Birth weight babies were 136 (45.9%). 53 (17.9%) babies required admission at Neonatal Intensive Care Unit. Conclusion: Proper antenatal care, institutional delivery and postnatal care help in reducing maternal and perinatal morbidity and mortality in adolescent pregnancy. Prevention of adolescent pregnancy can only be achieved by education of girl child, marriage at legal age, prevention of unwanted pregnancy along with proper health and life skill education to both boys and girls.

INTRODUCTION do not use and are unaware of contraception. Pregnancy WHO1 defines an adolescent as a person aged 10 to 19 and childbirth carry more risk in adolescents than in adults years. Ignorance regarding sexuality and reproduction because the adolescent girl is not yet mature physically along witha dventurous nature and poor negotiation skills and emotionally for motherhood. Teenage mothers are predisposes unmarried girls for early sexual activity that more likely to have children with low birth weight, may lead to various problems like unwanted pregnancy inadequate nutrition and anaemia. And they are more and STIs that may cause psycho-social-economical likely to develop cervical cancer later in life. Early problems for the adolescent girl. Adolescent Pregnancy motherhood can affect the psychosocial development of means pregnancy in a woman aged 10-19 years. It can be the infant. The occurrence of developmental disabilities used synonymously as Teen Pregnancy. About 16 million and behavioral issues are increased in children born to girls aged 15 to 19 years give birth every year – roughly adolescent mothers. 11% of all births worldwide. The vast majority of The risk of dying from pregnancy related cause is much adolescents' birth occurs in developing countries. In our higher for adolescents than for older women and greater country, where 47.4% of girls and in Gujarat where 38.7% is the risk for younger the adolescent. The risk of maternal of girls are married before the age of 18 years2 , there is a mortality is higher for adolescent girls, especially those high unmet need of contraception, as majority of couples under age, 15 compared to older women. Pregnancy in Correspondence Address : Dr Rajal V Thaker 3/A Manav Flats, St Xaviers College Corner, Ahmedabad 380 009 Email: [email protected]

100 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 unmarried teen not only creates social problem but also Table I: Antenatal problems in Adolescent Pregnancy there is a high risk of unsafe abortion.15 % of all unsafe Antenatal problems No Percentage abortions in low and middle income countries are among adolescent girls aged 15-19 years.3 Pregnancy in this age Anaemia 172 56.7 group adds to the national hazards by contributing to Preterm labour 54 17.8 population explosion especially in our country. PIH 21 6.9 MATERIAL AND METHODS Eclampsia 9 2.9 This retrospective observational study was carried out at STI/HIV 1 0.3 Department of Obstetrics and Gynaecology of our institute from 1st September 2011 to 31 August 2012 Table II: Outcome of Pregnancy amongst pregnant adolescents. Reproductive outcome N = 303 Outcome of PregnancyNo Percentage was studied in all adolescent girls (completed age less N = 9 (3%) MTP 2 0.6 than or equal to 19) who were admitted at our institute. Data was analyzed from their case papers and their feto- Abortion 5 1.6 maternal outcome was studied. Ectopic Pregnancy 2 0.6 RESULTS N = 294 (97%) Vaginal Delivery 199 65.6 During the study period, total number of pregnant patients LSCS 95 31.3 was 5851 who were admitted for delivery and abortion related care. Out of this, pregnant adolescent were 303. Table III: Birth Weight Hence, proportion of adolescent pregnancy in our study was 5.1%. Our study showed that, out of 303 adolescents, Birth Weight (kg)N = 296 No. Percentage 299 (98.6%) were married, while 4 (1.3%) were < 1 2 0.6 unmarried. 1- 1.4 18 6.0 Out of 303 pregnant adolescents, 211(69.6%) were of 19 1.5 – 1.9 35 11.9 years of age and 87 (28.7%) were of 18 years of age. Hence, 298 (98.3%) were above 18 years of age. 2.0 – 2.4 81 30.8 2(0.66%) belonged to 17 years of age and 1 (0.33%) each 2.5 – 2.9 115 35.4 belonged to 13, 14 and 15 years of age. Out of 4 (1.3%) > 3 45 15.2 unmarried adolescents, 3 (0.99%) were minors of 13, 14 1nd 15 years of age and 1(0.3%) was of 19 years of age. Our study revealed that, 48 (15.8%) were illiterate, 200 performed. 2 (0.6%) had First trimester and 1 (0.3%) had (66%) had primary education, 52 (17.1%) had secondary second trimester complete abortion. Laparotomy for education and only 3(0.9%) studied up to higher ectopic pregnancy was done for 2 (0.6%). secondary. None were studying at a college. There were 294 deliveries. There were 3 twins; hence 270 (89.1%) of pregnant adolescents were primigravia. total babies born were 296. Spontaneous vaginal delivery 27 (8.9%) were second gravida and 6 (1.9%) were third occurred in 199 (65.6%), out of which 54 (17.8%) were gravida. 15 (4.9%) couples ever used some method of preterm vaginal delivery and 145 (47.9%) were full term contraception. In present study, 281 (92.7%) had taken at vaginal delivery. 95 (31.3%) had Lower Segment least oneAnte Natal Care (ANC) Caesarean Section (LSCS). Out of 296 babies born, 268 (90.5%) were live birth and 28 (9.4%) were Still births. 53 172(56.7%) of pregnant adolescents had anaemia. Pre (17.9%) babies required Neonatal Intensive Care Unit term labour occurred in 54 (17.8%). Pregnancy Induced (NICU) admissions. In our study, Low Birth Weight (LBW) Hypertension (PIH) and Eclampsia occurred in 21 (6.9%) babies were 136 (45.9%) where as 160 (54%) of babies and 9 (2.9%) respectively. 1(0.3%) of pregnant were of more than 2.5 kg. adolescent girl had Human Immunodeficiency Virus (HIV) infection. DISCUSSION First and second trimester Reproductive loss of 9 (2.9%) The incidence of teenage pregnancy shows marked was reported in our study. Out of this, Medical Termination variation in developed and developing countries.3 Births of Pregnancy (MTP) was performed in 2 (0.6%). 5 (1.6%) to adolescents as a percentage of all births range from had abortion. 2 (0.6%) were diagnosed as missed about 2 % in China to 18 % in Latin America and abortion, hence Dilatation and Evacuation (D/E) was Caribbean. Worldwide, just seven countries account for

101 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 half of all adolescent births: Bangladesh, Brazil, Congo, components of ANC are more likely to be received by Ethiopia, India, Nigeria and United States of America. As women in urban areas. 4 per DLHS III (District level Household & Facility Survey), There are many health risks in adolescent pregnancy. in India, overall incidence of adolescent pregnancy is 172(56.7%) of pregnant adolescents had anaemia. This 5.6% (rural 6.4% and urban 3.5%) there is a wide range of data is comparable to NFHS 3 data2 , where 55.7% of variation amongst states: West Bengal leads in teenage adolescents were found to be anaemic. In our study, mild, pregnancy at 14%, followed by Karnataka at 11%,Andhra moderate and severe anaemia was present in 139 (46%), Pradesh at 10 %, Bihar at 8 % and Chattisgarh at 7 %. 24 (8%) and 9 (3%) respectively. Severe anaemia can Goa and Kerala has lowest adolescent pregnancy rate of lead to preterm labour, low birth weight and related 2% and 3% respectively, where as Gujarat has 3.4% of complications, post partum haemorrhage and sepsis7 in adolescent pregnancy. Our study showed that, out of 303 addition to impaired physical and cognitive development, adolescents, 299 (98.6%) were married, while 4 (1.3%) and increased risk of morbidity in children and reduced were unmarried. In a study by Bhalerao et al5 and Shruti D 6 work productivity in adults.Anaemia contributes to 20% of et al , incidence of pregnancy among unmarried all maternal deaths. Iron deficiency anaemia is one of the adolescents was 3 % and 5.63% respectively most common causes of anaemia during pregnancy that 211(69.6%) were of 19 years of age and 87 (28.7%) were can be corrected by proper diet and oral iron of 18 years of age. Hence, 298 (98.3%) were above 18 supplementation. In endemic areas, control of malaria years of age. 2(0.66%) belonged to 17 years of age and 1 and worm infestation during antenatal period is also (0.33%) each belonged to 13, 14 and 15years of age. Out recommended. of 4 (1.3%) unmarried adolescents, 3 (0.99%) were Pre term labour occurred in 54 (17.8%). Bhalerao A et al5 minors of 13, 14 1nd 15 years of age and 1(0.3%) was of and Chahande MS8 have reported that, 16% had preterm 19 years of age. 270 (89.1%) of pregnant adolescents vaginal delivery. Chen XK et al9 have reported an were primigravia. 27 (8.9%) were second gravida and 6 association between teenage pregnancy and preterm (1.9%) were third gravida. delivery. In our study, only 48 (15.8%) were illiterate, 200 (66%) PIH and Eclampsia occurred in 21 (6.9%) and 9 (2.9%) had primary education, 52 (17.1%) had secondary respectively. Many studies have concluded that, there is education and only 3(0.9%) studied up to higher high incidence of PIH and Eclampsia in adolescent secondary. No one was studying at present. pregnancy, but a WHO review concluded that there Early marriage in our society is associated with low levels probably is no special risk to adolescent mothers of of schooling and education as well as early pregnancies. hypertension associated with their young age. However, Attainment of higher education is associated with better hypertension is the most common complication of awareness and wisdom, and consequently an urge for pregnancy amongst women having their first child and is professional pursuit and desire for economic therefore a common complication for many adolescent independence. This in turn leads to late marriage and mothers10 . conception. Preventing unintended adolescent In our study, 1(0.3%) of pregnant adolescent girl had HIV. pregnancies and investing in girls' education, health and The prevalence of HIV among the youth population is 0.11 rights have powerful effects in other areas of their lives. percent. HIV prevalence2 is lower among youth age 15-19 Girls who are educated are likely to marry later and to (0.04%) than among both older youth (0.18%) and the have smaller, healthier families. Education helps girls to older cohort age 25-49 (0.38%) know their rights and claim them, for themselves and their families. Education can translate into economic There were 294 deliveries. There were 3 twins; hence opportunities for women and their families. Educated total babies born were 296. Spontaneous vaginal delivery young women offer a powerful boost to their families' occurred in 199 (65.6%), out of which 54 (17.8%) were wellbeing, contributing to increased household income preterm vaginal delivery and 145 (47.9%) were full term and savings, better family health and improved vaginal delivery. 95 (31.3%) had LSCS. Indications of opportunities for future generations. Combined, their LSCS were Cephalo-Pelvic Disproportion (CPD) in 43 actions can help lift communities and countries out of (45.2%), fetal distress in 15(15.7%), Non progress of poverty3 . labour in 13 (13.6%), PIH and abnormal presentation in 10 (10.52%) each, previous caesarean section and In present study, 281 (92.7%) had taken at least one ANC Accidental Haemorrhage in 2 (2.1%) each. which is indeed a good finding. National Family Health 2 Opinions on modes of delivery by operative interventions Survey (NFHS) 3 data shows that, in India; 77.3% of 11 12 teenage mothers have taken at least one ANC. All in teenage pregnancy differed widely. Al-Ramahi et al have reported that, because of CPD, there is higher rate

102 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 of operative interventions and instrumental deliveries. of girl child, marriage at legal age, prevention of unwanted Eure CR e al13 have reported lower rates of operative pregnancy along with proper health and life skill education interventions due to higher frequency of low birth weight to both boys and girls irrespective of whether they live in babies. rural or urban areas. First and second trimester Reproductive loss of 9 (2.9%) REFERENCES was reported in our study. Out of this, MTP was performed in 2 (0.6%). 5 (1.6%) had abortion. Out of them, 2 (0.6%) 1. http://www.who.int/medicacentre/factsheets/fs345 0th were diagnosed as missed abortion, hence D/E was /en/index.html,fact sheet N 345 August 2011, 64 world Health assembly 2011 as accessed on 24th September 2012 performed. 2 (0.6%) had First trimester and 1 (0.3%) had second trimester complete abortion. In a study by 2. A profile of youth in India, www.nfhs.org as accessed on 24 Bhalerao A et al5 , 8% had spontaneous abortion in 1st September 2012 and second trimester. Laparotomy for ectopic 3. http://www.unfpa.org/public/home/factssheets/ pregnancy was done for 2 (0.6%). young_people#getfacts as accessed on 24 September 2012 Pregnant unmarried adolescent girls often do not come to 4. http://www.rchiips.org/PRCH-3.html as accessed on 24 tertiary care hospital. In our study, only 4 (1.3%) September 2012 unmarried adolescent girls with pregnancy were reported. 5. Bhalerao A, Deasai S, Dastur N et al. Outcome of teenage Out of them 3 were minors, of 13 years, 14years and 15 preganacy J postgrad Med 1990;36:136-9 years of age. All of them were having history of abuse. 6. Shruti D, Reena W. Teenage Pregnancy. Bombay Hospital MTP was performed in 2 (0.6%) and 1(0.3%) had Journal.2008;50(2):236-239 complete first trimester abortion. One unmarried rd adolescent girl was of 19 years of age, who was engaged. 7. Williams Obstetrics, 23 edition; 1079- 81 She was diagnosed with rupture ectopic pregnancy and 8. Chahande MS, Jadhao AR, wadhva SK et al. Study of some laparotomy was performed. epidemiological factors in teenage pregnancy- Hospital based case comparision study. Indian J Community Med In our study, out of 296 babies born, 268 (90.5%) were live 2202;27 (3):106-108 birth and 28 (9.4%) were Still births. 53 (17.9%) babies 9. Chen XK, Wen SW, Fleming N et al. Teenage pregnancy 6 required NICU admissions in a study by Shruti D et al , the and adverse birth outcomes: a large population based total percentage of spontaneous abortion, macerated still retrospective cohort study. Int J Epidemiol 2007; 36:368-73 births and fresh still births was 9.84% which is quite high 10. WHO. 2004. Adolescent Pregnancy, Issues in Adolescent compared to 6.97% in general population. Health and Development page 21-22 According to WHO, birth weight of less than 2.5 kg is 11. Prianka M,R.N.Chaudhuri,Bhaskar Paul.Hospital-based Perinatal considered as LBW. In our study, LBW babies were 136 Outcomes and Complications in Teenage Pregnancy in India. J (45.9%) where as 160 (54%) of babies were of more than Health Popul Nutr 2010 Oct;28(5):494-500 2.5 kg. Bhalerao A et a5 l have reported similar finding of 12. Al-Ramahi M, Saleh S. Outcome of adolescent pregnancy 46.2% LBW babies and 53.8% having birth weight of 2.5 at a university hospital in Jordan. Arch GynecolObstet kg or more. LBW is a key predictor of malnutrition and an 2006;273:207-10. important determinant of child mortality14 . Prianka M et al 11 13. Eure CR, Lindsay MK, Graves WL. Risk of adverse have found that the number of LBW babies was more in the pregnancy outcomes in young adolescent parturients in an case of teenage mothers (38.9%) compared to the adult inner-city hospital.Am J Obstet Gynecol 2002; 186:918-20. mothers (30.4%). Babies born to teenage mothers are 14. Kushwaha KP, Rai AK, Rathi AK et al. Pregnancies in likely to be premature, and hence, the incidence of low adolescents: fetal, neonatal and maternal outcome. Indian birth weight is higher in them. Pediatr 1993; 30:501-5 15 (4.9%) couples ever used some method of contraception. The contraceptive prevalence rate among 15-19 age group is 13 percent compared to 33 % in age group of 20-24 years. 2 No maternal mortality was reported in present study.

CONCLUSION Proper antenatal care, institutional delivery and postnatal care help in reducing maternal and perinatal morbidity and mortality in adolescent pregnancy. Prevention of adolescent pregnancy can only be achieved by education

103 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 CASE REPORT Anesthetic management for emergency caesarean hysterectomy in a patient with placenta accreta Smita R. Engineer*, Chirag Patel**, Mrunalini Patel**, B. J. Shah*** * 2nd year resident doctor, ** Associate Professor, *** Professor & Head of unit Department of Obstetrics and Gynecology F-3, Department of Anesthesia, B. J. Medical Collage, Civil Hospital, Ahmedabad-16. KEY WORDS : Obstetric hemorrhage, Placenta accreta, Transfusion of Blood & Blood Products.

ABSTRACT : Placenta accreta is one of the most feared complications in obstetrics. It occurs when the placenta is abnormally adherent to the uterus, often resulting in complications in the peripartum period such as severe haemorrhage, a possible need for caesarean hysterectomy1 Preoperative diagnosis of placenta accreta, perioperative management with infusion of blood and blood products help in reducing morbidity and mortality to a greater extent. We hereby present a case of placenta accreta taken for emergency caesarean section which ended up with obstetric hysterectomy.

INTRODUCTION Patient was taken in the operation theatre with a wedge The incidence of placenta accreta among deliveries is low under the right hip. Monitors (ECG, NIBP and SpO2) (0.04%). However it accounts for up to 50% of all were applied. Her baseline vital parameters were normal. Caesarean hysterectomies most of which are unplanned. Two wide bore peripheral intravenous lines were secured. As diagnosis cannot be established definitively with Premedication included inj.Glycopyrrolate 0.2 mg IV, inj ultrasound, diagnosis can be made only at surgery. This Ranitidine hydrochloride 50 mg IV, inj Ondansetron has anaesthetic implications because it is necessary to hydrochloride 4mg IV. After five minutes of prepare for the potential danger of major haemorrhage.1,2 preoxygenation, induction of anaesthesia was done with inj thiopental sodium 300mg IV. Tracheal intubation was Anaesthesia management of the haemorrhage consisted facilitated by inj succinyl choline 75 mg IV. Anaesthesia of blood and fluid replacement, guided by assessment of was maintained with O22 (50%), N O (50%), the amount of blood loss along with heart rate, urine sevoflurane(0.2-1.5%) and inj. Atracurium bisylate. output and systemic blood pressure. General Analgesia was provided with inj. Diclofenac sodium 75 mg anaesthesia is preferred due to the longer operating IV. times, massive haemorrhage and need for extension of surgery including iliac vessel exposure.2 A healthy female baby of 2.1kg with normal apgar score was delivered. Thereafter, inj Methargine 0.2mg IV and MATERIALS AND METHOD inj.Oxytocin infusion (20 units in 500 ml 5% Dextrose) A 25 year old, weighing 50kg, 3rd gravida female were started. There was massive bleeding and it was presented for an emergency caesarean section. Her past difficult to remove placenta. Immediately obstetrician obstetric history included two previous caesarean sec decided to go for caesarean hysterectomy. During tions for cephalo-pelvic disproportion under spinal surgery blood loss was more than two liters. Intra- anesthesia uneventfully. There was no significant past operative tachycardia and hypotension was corrected medical or surgical history. All routine investigations were with colloids, 2 units of whole blood, 3 units of PCV and 3 within normal limits except Haemoglobin 7.9 gm%. units of FFP. At the end of surgery neuro muscular block Ultrasonography of abdomen shows low lying placenta was reversed with inj. Glycopyrrolate 0.4 mg IV and inj. with loss of interface between placenta and myometrium Neostigmine sulphate 2.5mg IV. In immediate suggesting placenta accreta. For emergency caesarean postoperative period patient was conscious, cooperative, section, general anesthesia with ASA grade IV was with adequate muscle tone and power. Her vitals were planned. In anticipation of massive blood loss, adequate stable. In the postoperative room O was supplemented whole blood and blood products were kept ready. A 2 dopamine hydrochloride infusion was available in an with vent mask and 2units of PCV was infused. She had event for hypotension. an uneventful postoperative course.

Correspondence Address : Dr. Smita R. Engineer 232A, Lane 16, Manekbaug Society, Ambawadi, Ahmedabad-380015. E-mail : [email protected]

GMJ 104 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 DISCUSSION Unfortunately, most cases of placenta accrete are Placenta accreta refers to a placenta that is abnormally encountered without warning in women who are not adherent to the uterus. The incidence of placenta accreta prepared for the possibility of hysterectomy. Control of is increasing, primarily as a consequence of the potentially life-threatening hemorrhage is the first priority; increasing caesarean delivery rate.3 The risk increases however the patient's desire for future fertility must be 5 from 24% with one previous caesarean section to 67% in taken into consideration before going for hysterectomy. women with 3 or more prior caesareans. Other risk CONCLUSION factors are uterine scarring from myomectomies, uterine Anesthetic management of placcent accreta will depend 4 curettages and infections. on available personnel, anesthesia equipment for Placenta accreta is noted at the time of delivery or C/S massive transfusion. The goals were to deliver a healthy with difficulty in separating the placenta from uterine wall. newborn and to devise a surgical approach which would However it may be possible to detect accreta with minimize blood loss and provide a dry surgical field. In this transvaginal ultrasound, 3- D USG and MRI. case preoperative diagnosis and the coordination of a Ultrasonography can diagnose 78% to 100% of cases. multidisciplinary team effort determined successful Antenatal recognition of placenta accreta and careful outcome. planning by obstetrician and anesthesiologist can REFERENCES 3 decrease blood loss and reduce serious complications. 1. Ted Hunter MD, Simcha Kleiman MO.Obtetric K,Anaesthesia for Caesarean hysterectomy in a patient with a. preoperative In our case, USG abdomen showed possibility of placenta diagnosis of placenta excreta with invasion of the urinary accreta. Therefore we planned for general anaesthesia bladder .Can JAnaesth 1996 /43:3 /pp246-51 and blood and blood products were kept ready. 2. C. F.Weiniger, T.Elram, Y.Ginosar, D. Mankuta, C. Weissman, Y. Ezra,Anesthetic management of placenta accrete: use of a pre- Anesthetic management of caesarean section for operative high and low suspicion classification† Anaesthesia placenta accretes is controversial. Many anesthetist Volume 60, Issue 11, pages 1079–1084, November 2005 believe that general anesthesia is mandatory for 3. www.developinganaesthesia.org/index2.php? caesarean section.. Regional anesthesia depends on option=com_content... Placenta praevia. Contributed by David position of placenta, urgency of situation and the extent of Pescod. Monday, 16 April 2007. PLACENTA. PRAEVIA AND ANAESTHESIA. Obstetrician any continuing antenatal blood loss. Regional anesthesia 4. Tong S Y P, Tay K H, Kwek Y C, Conservative management of in presence of uncontrolled hypovolaemia may be fraught placenta accreta: review of three cases. Singapore Med J Case with problems.4 Report 2008; 49(6) :e156 Pre-operative preparation of the patients suspected of 5. DavidA. Miller, MD Obstetric Hemorrhage having placenta accreta is important given the potential www.obfocus.com ›Articles - Cached by BDA Miller - Cited by 1 - Related articles for rapid and massive blood loss. Failure of the placenta 2 Nov 2004 – Obstetric Hemorrhage: Uterine Atony,Placenta to separate easily resulted in massive and sometimes Previa,PlacentaAccreta, uncontrolled haemorrhage.2 Therefore, it is prudent to place large bore intravenous access prior to the start of surgery and to be prepared with blood products in the room. Colloid solution is more efficacious in fluid. Blood transfusions are required in more than 50% of patients with placenta accrete. Massive transfusion can cause dilutional thrombocytopenia and coagulopathy, which can be treated with appropriate blood component (FFP, Platelet)2,4,5 . The estimated blood in emergency cesarean hysterectomy was 2526 1240ml, which is significantly more than in elective cesarean hysterectomy (1319 396ml)4 . Severe bleeding and the surgical procedures performed in an attempt to control it are the major sources of maternal morbidity and mortality in cases of placenta accreta.4 Two units of whole blood, three units of fresh frozen plasma and three units of packed cell volume were infused to our patient to maintain intravascular volume.

105 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 CASE REPORT Peutz-Jeghers syndrome Swati B. Parikh*, Biren J. Parikh**, Hitesh A. Prajapati***, C.K. Shah**** , N.R. Shah **** *Associate Professor, **Assistant Professor, ***Resident Doctor, **** Professor, ****Professor & Head Pathology Department, AMC MET Medical College, Smt. N.H.L.Municipal Medical College KEY WORDS : Peutz-Jeghers syndrome, hamartomatous polyps, mucocutaneous pigmentation

ABSTRACT : Peutz-Jeghers syndrome (PJS) is a rare, autosomal dominant disorder responsible for mucocutaneous pigmentation and gastrointestinal hamartomatous polyps. We present a case of Peutz-Jeghers syndrome with brief review of literature in an 18-year-old female presented with abdominal pain, vomiting & melena. The patient had pigmented lesions on the face, lower lip and buccal mucosa. The imaging studies revealed intussusception with multiple polyps in small intestine. The polyps revealed histological features of hamartomatous polyps.

INTRODUCTION consistent with mesenteric fat within an intussusception. Peutz-Jeghers syndrome is an autosomal dominant inherited The patient underwent an exploratory laparotomy. Small bowel condition determined by a mutation localized at 19p13.3; segmental resection with end to end anastomosis was characterized by the occurrence of gastrointestinal performed. The specimen was sent for histopathology hamartomatous polyps in association with mucocutaneous examination. Post-operative course was uneventful. hyperpigmentation. The diagnosis of PJS is based on clinical Histopathology examination findings and histopathological patterns of polyps. Peutz- Jeghers syndrome is associated with significant morbidity, The specimen consisted of a 25 cm portion of small bowel that variable clinical course and considerable predisposition to contained multiple pedunculated polyps on mucosal surface gastrointestinal & non-gastrointestinal malignancies. An overall (Fig: 1b). The largest polyp measured 3.5 x 2 cm and the recommendation for PJS patients includes not only smallest measured 1 x 0.8 cm. The cut surface of the polyp was gastrointestinal multiple polyps resolution, but also regular homogenous, white. lifelong cancer screening. Early detection and proper Microscopic examination of polyps revealed a core of arborizing surveillance are vital to minimize the risk of carcinoma. smooth muscle that supported non-neoplastic small bowel CASE REPORT mucosa, suggestive of hamartomatous polyp (Fig: 2). Aggregates of cystically dilated benign glandular structures and An 18-year-old female was admitted with sharp and intermittent pools of mucin were present within the submucosa and abdominal pain, which was located in the periumbilical region. muscularis propria at the base of the polyp, a finding that is The patient also reported nausea and several episodes of non- consistent with epithelial misplacement in a Peutz-Jeghers bilious, non-bloody vomiting. The patient had complained polyp. Neither adenomatous change nor malignancy was blackening of stool for five days. Physical examination revealed observed after thorough examination. multiple, black coloured pigmented lesions on the face, lower lip, and buccal mucosa; which the patient had since childhood (Fig: On the basis of hamartomatous small intestinal polyposis and 1a). On abdominal examination, epigastric and periumbilical clinical manifestation of mucocutaneous pigmentation, the tenderness, diminished bowel sounds, and a possible epigastric diagnosis of Peutz-Jeghers syndrome was rendered. mass were observed. Laboratory investigations revealed low hemoglobin concentration: 8.2 g/dL (N: 12 to 16 g/dL). Blood indices & peripheral blood smear examination suggested microcytic hypochromic anemia. Stool examination revealed positive benzidine test for occult blood. Routine blood chemistry reports were unremarkable. Barium follow through study showed multiple intraluminal filling defects carpeting the small bowel, suggestive of polypoid lesions in small intestine. Spring coiled appearance of jejunum 1a 1b was noted in left upper abdomen, suggestive of intussusception Figure - 1a : Figure - 1b : with proximally dilated bowel loops. Abdominal ultrasonography Pigmentations on the Multiple pedunculated (US) showed a large heterogeneous mass in the upper buccal mucosa & lower polyps in small intestine in a abdomen that measured 5.3 x 3.5 x 8.6 cm. The mass had a lip in a patient with Peutz- patient with Peutz - Jeghers “pseudokidney” appearance with central, high echogenicity; Jeghers syndrome. syndrome. Correspondence Address : Dr. Swati B. Parikh 203, 2nd Floor, Shanti Tower, Nr. Tulsi Party Plot, Vasna, Ahmedabad-380007 E-mail: [email protected]

GMJ 106 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 on the lips, around the mouth, eyes, nostrils, on the buccal mucosa; and sparsely on the fingers, soles of the feet, palms, anal area and intestinal mucosa.(7) The mucocutaneous lesions of PJS are considered to be hamartomatous in origin and without potential of becoming malignant. Gastrointestinal hamartomatous polyps are another classic finding of Peutz-Jeghers syndrome. Although these polyps are most commonly found in the small intestine, they can occur anywhere from stomach to rectum. The median time to first presentation with polyps is about 11-13 years of age and approximately 50% will Figure 2 : PJS hamartomatous polyp demonstrating the have experienced symptoms by the age of 20 years.(7) arborizing (branch tree like) pattern of smooth muscle Patients with PJS often present with a history of proliferation upon which rests the small intestinal mucosa intermittent abdominal pain due to small bowel (Hematoxylin-Eosin stain, magnification x100). intussusception caused by the polyps. Some intussusceptions spontaneously reduce; others lead to DISCUSSION development of small bowel obstruction. Peutz-Jeghers The primary description of PJS was published by Peutz polyps can also ulcerate, leading to acute blood loss or in 1921 in one Dutch family (the Harrisburg family) as a chronic anemia. Although Peutz-Jeghers polyps are most gastrointestinal familial polyposis with pigmentations.(1) commonly found in the gastrointestinal system, they can Jeghers specified the description in 10 cases from also occur in extraintestinal sites such as kidney, ureter, different families in his work in 1949 and defined the gallbladder, bronchial tree, nasal passages etc. relations between pigmented lesions, gastrointestinal Individuals with PJS are at risk for the development of polyposis and increased risk of carcinoma; gastrointestinal & non-gastrointestinal malignancies. approximately half of his patients suffered from Among the non-gastrointestinal type; pancreas, lung, gastrointestinal malignancy.(2) breast, uterus, cervix, ovary, testis & thyroid being the major sites of malignancies.(7,8) In a study of Hearle N et PJS, as with the other hamartomatous syndromes, has al,(9) 96 cancers were found among 419 PJS patients. This an autosomal dominant pattern of inheritance with both study reported the risks of developing gastrointestinal familial and sporadic transmission. The gene associated cancer (31%), breast cancer (31%), gynecologic cancer with PJS is a serine-threonine kinase, the tumour (3) (18%), pancreatic cancer (7%), and lung cancer (13%) by suppressor gene; located on chromosome 19p13.3. 60 years of age. Individuals with PJS are also at risk for Hemminki and coworkers and Jenne and associates developing rare sex cord tumors. Women are at risk for independently identified the gene in this region as sex cord tumors with annular tubules and men are at risk LKB1/STK11 (serine/threonine-protein kinase 11, which for developing Sertoli cell tumors. is also known as LKB1).(4, 5) This gene has been reported The Peutz-Jeghers polyp varies in size from <1 cm to >3.5 in 80% of patients with PJS. Up to 25% of recorded cases cm in diameter, and may be pedunculated or sessile. of PJS do not have family history. Those sporadic cases Because it appears to be composed of non-neoplastic probably arise due to new mutation of STK11 gene or low tissue normally found at the site, the Peutz-Jeghers polyp (6) penetration. In the present case, there was no positive is generally considered a hamartomatous polyp but with family history of Peutz-Jeghers syndrome. an abnormal growth pattern. The most characteristic The Peutz-Jeghers syndrome consists of two major feature of a Peutz-Jeghers polyp is a central core of components: hamartomatous polyposis of the smooth muscle that extends into the polyp in an arborizing gastrointestinal tract and mucocutaneous fashion (Christmas tree like appearance) and that is pigmentation.(6, 7) The incidence of PJS is reported to be 1 covered by either normal or hyperplastic mucosa native to (8) the involved site. Adenomatous & carcinomatous in 150,000 to 200,000 individuals. Mucocutaneous (10) pigmentation is a characteristic finding of PJS and is changes have been described in Peutz-Jeghers polyps. present in most, but not all, patients who have the Epithelial misplacement, also referred to as disease. The hyperpigmented lesions contain melanotic pseudoinvasion, is another feature seen in some Peutz- deposits and commonly manifest in infancy and Jeghers polyps. It is characterized by cystically dilated childhood. Pigmented lesions could fade during puberty benign glands and supporting lamina propria within the submucosa, muscularis propria, or subserosal layers of and adulthood.(6) The pigmented lesions are often seen the gut adjacent to a polyp and extravasated mucin pools.

107 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 This feature can mimic the appearance of invasive gastrointestinal malignancies in PJS, careful screening of adenocarcinoma. However, noting the lack of epithelial the patients is recommended. It is necessary to dysplasia, the presence of supporting lamina propria and the absence of a desmoplastic stromal reaction can help investigate all first-degree relatives of the patient. avoid this interpretive error. REFERENCES The diagnosis of PJS is established by the presence of 1. Peutz JLA. Over een zeer merkwaardige, gecombineerde familiaire histopathologically confirmed hamartomatous polyps and pollyposis van de sligmliezen van den tractus intestinalis met die van de neuskeelholte en gepaard met eigenaardige pigmentaties at least two of the following clinical criteria: a family history van huid-en slijmvliezen (Very remarkable case of familial of PJS, the presence of mucocutaneous pigmentation polyposis of mucous membrane of intestinal tract and nasopharynx and the presence of small-bowel polyps.(8) accompanied by peculiar pigmentations of skin and mucous membrane; in Dutch). Nederl Maandschr v Geneesk 1921; 10: 134- Typical imaging features of Peutz-Jeghers syndrome 146. consist of multiple polypoid lesions involving the stomach, 2. Jeghers H, McKusick VA, Katz KH. Generalized intestinal polyposis small bowel and colon. Although the polyps are often and melanin spots of the oral mucosa, lips and digits; a syndrome of detected with barium studies, they can also be identified diagnostic significance. N Engl J Med 1949; 241: 1031-1036. with US or CT. Some authors have suggested using US 3. Mehenni H, Blouin JL, Radhakrishna U, Bhardwaj SS, Bhardwaj K, or magnetic resonance (MR) imaging for follow-up et al. Peutz-Jeghers syndrome: confirmation of linkage to chromosome 19p13.3 and identification of a potential second (11) imaging to reduce the lifetime radiation burden. Another locus, on 19q13.4.Am J Hum Genet. 1997;61:1327-1334. important imaging finding in Peutz- Jeghers syndrome is 4. Hemminki A, Markie D, Tomlinson I, Avizienyte E, Roth S, et al. A intussusception. serine/threonine kinase gene defective in Peutz-Jeghers syndrome. Nature. 1998;391:184-187. Over the years, the standard therapy for Peutz-Jeghers 5. Jenne DE, Reimann H, Nezu J, Friedel W, Loff S, et al. Peutz- syndrome has been laparotomy and bowel resection to Jeghers syndrome is caused by mutations in a novel serine remove symptomatic gastrointestinal polyps that cause threonine kinase. Nat Genet. 1998;18:38-43. persistent or recurrent intussusceptions. However, some 6. Vesna Živković et al. Hereditary Hamartomatous Gastrointestinal patients require multiple surgical resections, which can Polyposis Syndrome. Scientific Journal of the Faculty of Medicine lead to short gut syndrome. Because of this, it has been in Niš 2010;27(2):93-103. recommended that endoscopy be performed to remove 7. Marcela Kopacova, Ilja Tacheci, Stanislav Rejchrt, Jan Bures. all polyps. During each laparotomy, the small bowel Peutz-Jeghers syndrome: Diagnostic and therapeutic approach. World J Gastroenterol 2009 November 21; 15(43): 5397-5408. should be examined by means of intraoperative enteroscopy (IOE). Nowadays, double balloon 8. Michael Manfredi. Hereditary Hamartomatous Polyposis Syndromes: Understanding the Disease Risks As Children Reach enteroscopy (DBE) in combination with capsule Adulthood. Gastroenterology & Hepatology Volume 6, Issue 3 enteroscopy are the gold standard for the diagnosis and March 2010; 185-196. (7, 8) treatment of the small bowel hamartomatous polyps. 9. Hearle N, Schumacher V, Menko FH, Olschwang S, Boardman LA, et al. Frequency and spectrum of cancers in the Peutz-Jeghers CONCLUSION syndrome. Clin Cancer Res. 2006;12:3209-3215. Peutz-Jeghers syndrome is a rare, autosomal dominant 10. Karl H. Perzin, Mary F. Bridge, Adenomatous and Carcinomatous disorder characterized by mucocutaneous pigmentation Changes in Hamartomatous Polyps of the Small Intestine (Peutz- & gastrointestinal hamartomatous polyps. Because of the Jeghers Syndrome): Cancer 1982; 49: 971-983. increased risk of both gastrointestinal and non- 11. Kurugoglu S, Aksoy H, Kantarci F, et al. Radiologic work-up in Peutz-Jeghers syndrome. Pediatr Radiol 2003;33:766–771.

108 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 CASE REPORT Rupture of uterus at 14 weeks pregnancy with adherent placenta- a rare case reportancy '' in a rural based tertiary care hospital” Nipa Modi*, S.B Vaishnav**, Nitin S. Raithatha* *Associate Professor, **Professor & Head of the Unit Department of Obstetrics & Gynecology, Pramukhswami Medical College, Karamsad, Dist. Anand, Gujarat 388 325 KEY WORDS : Rupture of Uterus, Pregnancy, Placenta,

peritoneal cavity and full length horizontal rupture was INTRODUCTION present exactly on the old (previous) LSCS scar and Rupture uterus is one of the catastrophies faced by an through which placenta and abortus were coming out. It obstetrician in which every second of time is of vital was a fresh rupture without ragged margins. Placenta and importance. In India, incidence is High due to greater abortus with scar were removed manually because the number of unbooked obstetric emergencies (Incidence placenta was adherent at the site of previous scar and of 1: 224). Among booked cases are 12.5% of total relatives were not ready for obstetric hysterectomy, so number of rupture uterus cases. repair of ruptured scar was done. Patient was shifted to CASE REPORT the ward. Exactly after 5 hrs of laparotomy, again active vaginal bleeding started, with increase in the drain output. th A 28yrs old 6 gravida patient with previous one LSCS Relaparotomy was done and total obstetric hysterectomy was admitted on 11/8/08 evening with history of 3 months with drainage of broad ligament hematoma was done. of amenorrhea with severe abdominal pain, localised to Patient's PT and aPTT were altered. Thus, patient was in epigastrium, since past 4 hrs and history of vomiting once. DIC with Acute renal failure. Patient was shifted to SICU. There was no history of leaking or bleeding per vaginum. Patient developed ARDS with ARF and ultimately after so st She is a G6141. P A L 1 pregnancy – only one female live by many blood transfusions and hemodialysis, patient FTLSCS, 9 years old. ( Indication: ? fetal distress). survived and got discharged after 1 month of surgery. Total 20 units of PCV, 13 units of FFP,4 units of PRC were History of 4 MTPs at 3, 1.5, 2.5, 2 MA at the gap of 1.5-2 given. Uterus and other specimen were sent for years. This one is the present pregnancy. she is 14 wks 4 histopathological examination, and the report suggested days. On examination, her vitals were normal. On placenta percreta. abdominal examination, the uterus was of 14-16 weeks size. Scar of previous LSCS was present with no scar DISCUSSION tenderness. There was no abdominal distension, Rupture of uterus during labour is not uncommon. Most of guarding or rigidity. The fetal heart sounds were present them occur following a previous cesarean section and and regular by Doppler. On per speculum examination, involve dehisence of lower segment6 . there was no bleeding or leaking. On per vaginum examination, the cervix was non-dilated, non-effaced, Abnormal placental implantation in which posteriorly placed and soft. Her basic investigations were Accretaà adherance to uterine wall normal. In obstetric USG, 15 wks 4 days with fetal heart Increataà villi actually invade the myometrium rate 156/min at 5:15 PM on 11/8/09. So provisional Percretaà penetrate through the myometrium diagnosis was G P A L with 14 wks pregnancy with 6141 Abnormal placental adherence is found when decidual abdominal pain under investigation. Exactly 3-3.5 hours formation is defective. Associated condition include after admission patient's condition deteriorated. She implantation in the lower uterine segment over a previous developed abdominal distension with guarding and C.S. Scar, implantation over other previous uterine rigidity and epigastric tenderness. USG abdomen and incisions and implantation after uterine curettage. Other pelvis with urgent physician reference was advised to rule risk factor include nulliparity, previous in cession, MRP, & out any other cause of acute abdomen. USG report myomectomy. The risk factors include hemorrhage, suggested moderate amount of free fluid in the pelvis and shock, infection & rarely inversion of uterus. ? blood and ? uterine rupture, which was not there in previous USG. Patient looked more pale than at the time Successful treatments depends upon immediate blood of admission. Decision was taken for laparotomy. On replacement therapy and prompt hysterectomy. opening the abdomen, gross hemoperitoneum with 850 Our case in unusual and interesting because in a woman ml of blood + 500 gms of clots were removed from the with previous scar in lower uterine segment, rupture of Correspondence Address : Dr. Nipa Modi Shree Krishna Hospital & Pramukhswami Medical College, Karamsad 388325, Dist. Anand. Email id : [email protected]

109 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 the uterus occurred during early pregnancy with out any 6. Zelop, CM, ShippTD, Liebermant : Uterine rupture during labour in labour pains due the placenta percreta. Probably gravid uterus with one prior caeserian delivery – American Journal of Obstetrics & Gynecology 1999 181: 882-6 placenta percreta in this case was due to multiple uterine curretage (MTPs) [5] 7. James DK, Steer, Weiner, Gonik, High Risk pregnancies Management options 1572, 1573. Placenta percreta usually presents as postpartum 8. Innes G,Rosen p:An unusual case of abdominal pain and shock in hemorrhage when the placenta is manually extracted pregnancy ; case report and review of the literature.J emerg Med from the underlying myometrium. Postpartum 1985;2:361-366 hemorrhage occurs in 40% of cases[1] [5] Uncontrolled 9. Hutton L, Yang S, Bernstein J: Placenta Accreta A: 26 year, 47 hemorrhage usually repairs aggressive blood volume clinicopathologic review (1956-1981). N.Y.State J. Med 1983; May : 857-866 resuscitation and/or hysterectomy. Placenta percreta can 10. Waegemaekers C, Gerretsen G, Billing S : Acute abdominal pain also present as hemoperitoneum during the antepartum due to placenta percreta. Eur J. Obstet Gynecol Reprod Biol period when the chorionic villi completely invade the 1987;25:335-339. myometrium, resulting in rupture of the uterine wall. 11. Finberg HJ, Willians JW : Placenta accreta : Prospective Intrapartum rupture of the uterus typically occurs during songraphic diagnosis in patients with placenta previa and prior the second trimester of pregnancy but has been reported cesarean section. J Ultrasound Med 1992;11:333-343 as early as 12 weeks gestation.[1] [6] Placental invasion is a 12. Breen JL, Neubecker R. Gregori C.A. Franklin J: Placenta accreta, painless process and may not present clinically until the increta and percreta. A survey of 40 cases. Obsted Gynecol 1977; 49;43-47. uterine wall perforates or ruptures. Initial presentation may include hemorrhagic shock, acute abdominal pain, or 13. Filardo J. Nagey DA: DA: An usual presentation: Placenta percreta with uterine conservation J Perinatol 1990;10:206-208. fetal demise. Placental attachment and invasion to 14. Litwin MS, Loughlin KR, Benson CB, et al: Placenta percreta adjacent abdominal structures may also occur. Painless invading the urinary bladder Br. J Uni. 1989:64:283-286. hematuria may be the presenting complaint when the 15. Price FV, Resmik E, Heller KA, Christopherson WA: Placenta placenta penetrates through the uterus and into the previa percreta involving the urinary bladder; A report of two cases urinary bladder[7] [8] . Risk factors include previous and review of the literature. Obstet Gynaecol 1991;78:508-511. cesarean section; uterine curettage; placental abnormalities, including placenta accreta; placenta previa; delivery requiring maternal extraction; irradiation; neoplasm; caustic drugs; congenital anomalies; and cornual implantation of placenta [3] [10] [11] [12] [13] Hemoperitoneum and uterine rupture secondary to placenta percreta requires aggressive surgical management. Immediate cesarean section followed by hysterectomy yields the lowest mortality studies show a fourfold increase in the mortality rate of conservatively treated groups compared with patients treated with hysterectomy[1] [6] [11] . Summary : Placenta percreta results in abdominal pain, hemorrhagic shock and / or fetal demise. Although an uncommon occurrence, the emergency physician should consider the diagnosis in the gravid patient with abdominal pain, because aggressive surgical management reduces maternal mortality. REFERENCES 1. Cunningham FG Gant Nf, Leveno K Jatal William's obstetrics 2. Park EH Saches BP High Risk Pregnancyt management optiona, 2nd Epi. WB Saunders 20001: 3. Hopker M Fleckenstein G, placenta percreta in 10 wks pregnancy with consecutive hysterectomy 4. Imseis HM , MurthaAP,et al, spontaneous rupture of a primigravida uterus secondary to placenta percreta. J. Reproductive Medicine 1998, 43:23376 5. Arunkumar S Bhaskar Rao, K : Handbook of Obstetric and Gynecological emergencies- 7: 71, 72

110 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 CASE REPORT A Case of Severe Carbon Monoxide Poisoning Due to Gas Geyser with Cerebellar Involvement Dr Heli S Shah*, Dr. Shailesh H Darji**, Dr Krunal Padhiyar***, Dr Amit P Bhatt****, Dr Sudhir V shah***** KEY WORDS : Carbon Monoxide Poisoning; Gas Geyser, Cerebellar

ABSTRACT : Carbon monoxide is responsible for a large number of accidental domestic poisoning and deaths throughout the world. Diffuse hypoxic brain injury due to carbon monoxide poisoning while using gas geyser is very well known. We report a case of young male patient presented with hypoxic brain injury due to carbon monoxide poisoning while using gas geyser in bathroom which didn't have proper ventilation. There is involvement of bilateral cerebellum, which is very rare in such cases. Patient was treated with hyperbaric oxygen therapy and showed improvement on follow-up after three months.

CASE REPORT in appropriate doses. Patient was kept on neurocognitive, HISTORY : 30 year male science professor Mr. PC was neurobehavioral therapy and speech therapy. found unconscious in bathroom at one government guest FOLLOW-UP : On follow-up after three months patient house at Anand city, Gujarat in January 2013. He went to had some improvement in language and memory function take bath and was found unconscious in the bathroom by however still he was not able to do his job. His guest house staff. He was alone in room and last he was Addenbrookes score was improved to 76/100. seen in room thirty minutes before he was found DISCUSSION unconscious. The door had to be broken to rescue him. Apparently he was taking bath with hot water using gas Carbon monoxide (CO) is responsible for a large number geyser. He was brought to local hospital in comatose state of accidental domestic poisoning and deaths throughout and was given IV Fluids and primary treatment and then the world¹. CO is a colourless and odourless toxic gas shifted to one corporate hospital for further management. produced as a by-product of incomplete combustion of Patient regained consciousness within twelve hours but carbon-based fuels and substances. The neurologic remained in a state of altered sensorium for next twelve sequelae are the most frequent form of morbidity². The hours. He could not remember any events of the incident. pathophysiologic mechanisms of CO toxicity can be After that patient developed profound antegrade as well divided into hypoxic and cellular theories³. The affinity of as retrograde amnesia. No complaints of seizure or any CO for heme protein is approximately 250 times that of weakness of any limbs. oxygen, and the formation of carboxyhemoglobin reduces the oxygen-carrying capacity of blood, causing tissue EXAMINATION : Patient was conscious. His Mini-mental hypoxia⁴ . CO inhibits the mitochondrial electron state examination score was 14/30 and Addenbrookes transport enzyme system and activates score was 51/100. Patient was having mild confusion with polymorphonuclear leukocytes, which undergo disorientation to time, place and person and inability to diapedesis and cause brain lipid peroxidation, leading to register and recall things. He was having language the delayed effects of CO poisoning. The clinical dysfunction in the form of difficulty in comprehension and presentations and imaging features of CO poisoning are anomia. Otherwise no other neurological deficit. diverse. INVESTIGATIONS : All routine investigations including Acute and intense CO poisoning can lead directly to renal and liver function tests were normal. Arterial blood diffuse hypoxic–ischemic encephalopathy predominantly gas analysis was suggestive of acidosis with pCO2 50.1 involving the gray matter there is a predilection for the mmHg. EEG suggestive of diffuse encephalopathy. MRI temporal lobe and the hippocampus. Basal ganglia brain s/o bilateral symmetrical hyper intensity in T2 and mainly globus pallidus and occasionally caudate nucleus, FLAIR and restricted diffusion in bilateral basal ganglia putamen, and thalamus are involved in CO poisoning5 . and bilateral temporal cortical gyri and bilateral cerebeller Involvement of the brainstem and cerebellum may be a hemisphere s/o severe hypoxic encephalopathy. reflection of more severe poisoning because the posterior MANAGEMENT : After two days of the event patient was structures are more resistant to hypoxia. The lesions subjected for hyperbaric oxygen (HBO) therapy for 7 days usually appear as asymmetric hyperintense foci on T2- Correspondence Address : Dr. Shailesh H. Darji B-18, Doctors Quarters, NHL Medical College Campus, V. S. Hospital, Ellisbridge, Ahmedabad - 380006. E-mail : [email protected] GMJ 111 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 weighted and FLAIR images. Cerebeller involvement predicts poor prognosis in such patients as its suggestive of severe hypoxia6 . Such cases occurred when water used for bathing was heated by gas geysers fitted within ill-ventilated small bathrooms, and there was a clustering of such cases in winter months7 . The mainstay of treatment is 100% oxygen. In 1895, Haldane demonstrated that a mouse could be kept alive by exposure to HBO at the same time as CO. This seminal experiment established role of HBO8 . HBO has many benefits. The half-life of carboxyhaemoglobin at 3 absolute atmospheres of oxygen is only 23 minutes. It showed improved mitochondrial function, impairment of Image - 2 : Flair hpyerintensity in Temporal lobe platelet adhesion in the capillaries and inhibition of lipid peroxidation. But contrary to expectation, clinical trials of HBO have given conflicting results. Previous study demonstrated that HBO therapy reduced the incidence of neurological sequel and also demonstrated that neither clinical history nor the carboxyhaemoglobin level predicts which patients may show sequel after CO poisoning910 . But a recent Cochrane review suggested that firm guidelines regarding the use of HBO cannot be established¹¹. Ongoing trials will soon provide further information. In the absence of firm evidence most centres continue using HBO for severe neurological deficit including coma and for myocardial ischaemia. The decision about HBO will often depend on ease of access to a hyperbaric facility. The time-frame within which Image - 3 : Diffusion restriction in cerebellum hyperbaric oxygen is most effective is not known¹². While use of ECMO for severe potentially reversible cardio-respiratory failure could be a rescue strategy, we Recently extracorporeal membrane oxygenation (ECMO) need more well-designed studies of ECMO compared to suggested for patients with respiratory failure of a HBO in the context of neurological sequel. The availability reversible etiology including CO poisoning¹³. The of ECMO compared to HBO might be an important issue. association between ECMO and improved neurologic function is uncertain. The effect of ECMO on cerebral In present case bilateral cerebellum involvement was blood flow or oxygenation metabolism is controversial14 . suggestive of severe hypoxic injury due to CO poisoning and he was benefited with HBO therapy as shown on follow-up with improved clinical status and Addenbrookes score. REFERENCES 1. Mohankumar TS et al. J Forensic Leg Med. 2012 Nov;19(8):490-3. 2. Omaye ST.Toxicology2002; 180:139–150 . 3. Prockop LD. JNeuroimaging 2005;15:144–149. 4. O'Donnel P et al.Clin Radiol 2000; 55:273–280. 5. Chung-Ping Lo et al.AJR 2007; 189:W205-W211. 6. Benjamin Y.Huang et al. March 2008 RadioGraphics, 28, 417-439. 7. Prabhjeet Singh et al. 2008Apr-Jun; 11(2): 103–105. 8. Haldane JS. 1895;18: 201-7. 9. Thom SR et al.Ann Emerg Med. 1995;25:474-480. 10. Weaver LK et al.N Engl J Med. 2002; 347:1057-1067. 11. Juurlink DN et al. 2005;1:CD002041. 12. Ivan Blumenthal. J R Soc Med. 2001 June; 94(6): 270–272. 13. Yin-TangWang et al. J Med Sci 2010;30(3):101-105. Image-1 : Flair hpyerintensity in Globus pallidus 14. Iijima T et al. Intensive Care Med. 1995 Jan;21:38-44.

GMJ 112 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 CASE REPORT Goodpasture's Syndrome with Immune Thrombocytopenia: An unusual “Autoimmune Mosaic” Dr. Tripathi Sanjay B.*, Dr. Kapadia Vishakha K.**, Dr. Jethawa Ashish R.*** *Professor and Head, **Assistant Professor, ***Junior Resident Department of Pulmonary medicine, AMC MET medical college and L.G.Hospital, Maninagar, Ahmedabad. KEY WORDS :Goodpasture's syndrome, thrombocytopenia, alveolar hemorrhage

ABSTRACT Our case report is about a 28-year-old male who developed alveolar hemorrhage and thrombocytopenia without significant renal involvement. He was diagnosed to have Goodpasture's syndrome by the demonstration of increased titer of anti-GBM antibodies. The evaluation of the thrombocytopenia ruled out TTP due to the absence of a microangiopathic hemolytic anemia. While it was difficult to rule out a drug-induced thrombocytopenia, the most likely cause was an immune thrombocytopenia. This case portrays an unusual development of immune mediated thrombocytopenia in a patient with Goodpasture's syndrome.

INTRODUCTION WBC count was 14900/cumm; platelet count was Antiglomerular basement membrane(- anti GBM ) disease 136000/cmm. His routine biochemistry investigations (’), were normal including electrolytes. His blood urea was Goodpasture s syndrome the prototype of pulmonary 40 mg/dl, serum creatinine was 1.5 ng/ml. Routine urine renal syndromes, accounts for 18 to 32 percent of examination revealed proteinuria(2+,Dipstick) however immunemediated diffuse alveolar hemorrhage caused by gross haematuria was absent and urine output was circulating auto antibodies against alpha 3 chain of type IV adequate. basement membrane collagen. Simultaneous both renal Arterial blood gas analysis (ABG) revealed pH-7.42; and pulmonary involvement occur in 60-80% of the SpO -74%; PaO -58 mm Hg; PaCO -22 mm of Hg. As the patients, isolated glomerulonephritis occurs in10-30% of 22 2 condition deteriorated, Bi PAP support was initiated with patients and isolated diffuse alveolar hemorrhage occurs 100% FiO With further deterioration patient was in 5-10% of patients1 . The patient in this case report was 2. intubated and mechanical ventilation was started under presented with history of hemoptysis and breathlessness Fantanyl and midazolam sedation which improved the of 20 days duration. Patient was diagnosed to have ABG. Chest radiograph showed bilateral patchy dense Goodpasture's syndrome on the basis of anti-glomerular opacities with air bronchogram but without any evidence basement membrane antibodies (IgG) along with of fibrosis or cavity. Sputum (collected through microscopic hemoglobinuria (in plenty). The unusual endotracheal tube) or ET smear examination for acid fast aspect of this case was that the patient also developed a bacilli was negative on repeated examinations. Culture of concomitant immune mediated thrombocytopenia. sputum revealed normal flora. Frequent attacks of Thrombotic thrombocytopenic purpura (TTP) was moderate hemoptysis; dyspoea disproportionate to chest unlikely as there were no evidence of a microangiopathic radiography findings along with failure to wean from hemolytic anemia. This case report confirms previously ventilators warn us to suspect other etiology of alveolar reported findings which were noted in a very few sporadic hemorrhage. His repeat blood count showed platelet case reports about the possible association between count -82000/cmm. IgG and IgM for Dengue fever was Goodpasture's disease and thrombocytopenia. In negative. Patient was treated with four units of platelet addition, it adds to our current understanding of the rich concentrate (PRC) (because of active haemoptysis pathophysiology of autoimmune diseases in general and and decreasing platelet count) without any improvement supports the theory of an autoimmune mosaic, which has in platelet count which in fact decreased to 68000/cmm also been noted in various other autoimmune diseases. which favours immune mediated thrombocytopenia CASE REPORT destructing patient's as well as donor's platelets and A 28 years old male patient presented with history of ruling out drug induced thrombocytopenia. Test for hemoptysis and progressive breathlessness of 20 days Dengue antibodies was negative. Urine showed duration without any significant past and family history. microhemoglobinuria (in plenty). His anti- GBM antibody Patient was admitted to ICU of our institute. On (IgG) titer was positive suggesting Goodpasture's examination, patient had tachycardia, BP 160/96mmof syndrome and p-ANCA & c-ANCA were negative ruling Hg and was severely dyspnic with respiratory rate 44/min, out vasculitis. His BT, CT and PT were normal. His USG without any significant chest finding except few crept. At was inconclusive and Broncoscopy done at ICU to get the time of admission his hemoglobin level was 13.9gm%; broncoalveolar lavage(BAL) revealed bloody fluid Correspondence Address : Dr. Tripathi Sanjay B. 2, Shakuntal Society, Somnath Road, Usmanpura, Ahmedabad-380013. E-mail : [email protected]

113 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 bilaterally consistent with diffuse alveolar emorrhage. densebilateral alveolar infiltrates, oftenwith air- TTP was unlikely as there was no evidence of bronchograms. The demonstration of anti-GBM microangiopathic hemolytic anemia based on the dearth antibodies in tissue (typically kidney) or in serum is the of schistocytes and normal corrected reticulocyte count. cornerstone of the diagnosis. We continued ATT without Rifampicin as patient was Thrombocytopenia is a rare manifestation of already on ATT before admission at our institute.Because Goodpasture's syndrome. There are very few previous of this though it is very difficult to rule out Rifampicin case reports of thrombocytopenia associated with induced thrombocytopenia, platelet count never Goodpasture's syndrome, all of them reported as 3-5 improved – in fact, deteriorated even one week after thrombotic thrombocytopenic purpura (TTP) . There is withholding Rifampicin. Patient was treated with higher evidence that helper T (Th) cell-associated cytokine, antibiotics and hydrocortisone initially and then shifted to interleukin (IL)-12 is involved in the pathogenesis of 6,7 methylprednisolone in addition to other supportive thrombotic thrombocytopenic purpura . Furthermore, treatment including ventilator support and platelet rich Kalluri et al. developed a new mouse model of human concentrate (PRC). Plasmapheresis facility was not anti-GBM disease, in which crescentic glomerulonephritis available at our institute and considering poor patients and lung hemorrhage were associated with emergence of 8 condition we cannot shift the patient on ventilator for IL-12/Th1-like T-cell phenotype . plasmapheresis. Unfortunately patient succumbs with There was no evidence that our patient had TTP since his massive hemoptysis. corrected reticulocyte count was normal and he did not Serial X- rays showing bilateral alveolar infiltrates have a microangiopathic hemolytic anemia (absence of an elevated reticulocyte count and the absence of a significant number of schistocytes on the peripheral smear). This case further supports the theory of a “mosaic of autoimmunity” as it incorporated emergence of multiple autoimmune pathologies in the same individual9 . Immune mediated thrombocytopenia has also been observed in association with idiopathic pulmonary hemosiderosis in a case reported by Buchanan et al. with good response to corticosteroid and splenectomy10. REFERENCES DISCUSSION 1. Cosgrove GP, Schwarz MI. Vasculitis & the diffuse alveolar During the 1918-1919 influenza pandemic, the hemorrhage syndromes; Current diagnosis and treatment in pathologist Ernest Goodpasture (1866-1960) reported pulmonary medicine. about two patients with rapidly progressive and ultimately 2. Golberger ZD, Weinberger SE, Nicosia RF, Saint S, Young BA. fatal syndrome characterized by hemoptysis, anemia and Variations on a theme. N Engl J Med 2008; 359:1502-1507. renal failure. In 1950, Stanton and Tange described a 3. Watanabe H, Kitagawa W, Suzuki K, Yoshino M, Aoyama R, Miura series of patients with pulmonary–renal syndrome. It is N, Nishikawa K, Imai H. Thrombotic thrombocytopenic purpura in a not known whether these cases, or indeed if patient with rapidly progressive glomerulonephritis with both anti- Goodpasture's original case, had anti-GBM antibodies glomerular basement membrane antibodies and myeloperoxidase anti-neutrophil cytoplasmic antibodies. Clin Exp Nephrol. 2010 because the techniques for detecting these antibodies Dec; 14(6):598-601. were not yet available at that time. 4. Torok N, Niazi M, Al Ahwel Y, Taleb M, Taji J, Assaly R. Thrombotic Today the term Goodpasture's syndrome is used to thrombocytopenic purpura associated with anti-glomerular describe the combination of glomerulonephritis and lung basement membrane disease. hemorrhage in the absence of another specific cause (like Nephrol. Dial. Transplant. 2010; 25(10): 3446-3449. 5. Terryn W, Benoit D, Van LooA, Peeters P,Schepkens H, Cokelaere Wegener's granulomatosis), whether or not there are K, Vanholder R. Goodpasture's syndrome associated with circulating anti-glomerular basement membrane autoimmune thrombotic thrombocytopenic purpura an unusual antibodies2 . Goodpasture's syndrome is associated by case. Nephrol Dial Transplant. 2007 Dec; 22(12):3672-3. auto antibodies to the noncollagenous-1 domain of alpha 6. Takatsuka H, Takemoto Y, Okamoto T, et al. Thrombotic microangiopathy following allogeneic bone marrow 3 chain of type IV collagen in the basement membrane of transplantation. Bone Marrow Transplant 1999; 24:303-306. glomerular and alveolar tissue. Anti-GBM disease 7. Kakishita E. Pathophysiology and treatment of thrombotic typically affects individuals between 20 and 45 years of thrombocytopenic purpura/hemolytic uremic syndrome age with a distinct male predominance. Exposure to (TTP/HUS). Int J Hematol 2000; 71:320-327. cigarette smoke, hydrocarbon-containing solvents, hard- 8. Kalluri R, Danoff TM, Okada H, et al. Susceptibility to anti- glomerular basement membrane disease and Goodpasture metal dust, influenza A2 virus, chlorine gas, and d- syndrome is linked to MHC class II genes and the emergence of T penicillamine have been associated with anti-GBM cell-mediated immunity in mice. J Clin Invest 1997; 100:2263- disease. Most patients present with progressive dyspnea, 2275. widespread alveolar infiltrates, and hypoxemia; 9. Brickman CM, Shoenfeld Y. The mosaic of autoimmunity. Scan. J hemoptysis occurs in 80 to 94 percent. A cardinal feature Clin. Lab. Invest. Suppl. 2001; 235:3-15. 10. Buchanan GR, Moore GC. Pulmonary hemosiderosis and immune of Goodpasture's syndrome is the presence of GN. thrombocytopenia. Microscopic hematuria, red cell casts, or proteinuria are Initial manifestations of collagen-vascular disease. JAMA 1981; almost always present. Chest radiographs typically reveal 246:861-864

114 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 CASE REPORT Giant Gluteal Pleomorphic Liposarcoma – A rarity. Dr. Vikas Bathla*, Dr. Pukur Thekdi**, Dr. Yogendra D. Shah***, Dr. Mukesh Kothari****, Dr. Archit Patel*****, Dr. Parth Nathwani***** *Associate Professor, **Professor in surgery, ***Assistant Professor, ****Associate Professor, *****Third year resident , Department of Surgery, C. U. Shah Medical College and Hospital, Surendranagar. Gujarat state, INDIA. KEY WORDS : Giant, Liposarcoma, Pleomorphic

ABSTRACT Liposarcoma is the second most common soft tissue sarcoma in adults with a peak incidence between the fourth and sixth decade of life and slight preponderance towards male gender. Pleomorphic liposarcoma is a variant of liposarcoma defined morphologically by the presence of pleomorphic lipoblasts, is the rarest subtype. We report a case of giant gluteal liposarcoma which was treated with surgical excision and postoperative radiotherapy. A 35 year old female was admitted with painless rapidly growing mass in left gluteal region. The patient was managed by wide local excision. Pathological diagnosis was pleomorphic liposarcoma. Patient had postoperative radiotherapy and was free of disease for one year. Wide local surgical excision and postoperative radiotherapy is the most favoured treatment plan for pleomorphic liposarcoma. For such an unusual giant rapidly growing pleomorphic liposarcoma, a longer follow up is required to evaluate the recurrence and metastasis.

INTRODUCTION necrosed with multiple patches of ulceration and Liposarcoma is the second most common soft tissue fungation with foul discharge. No pulsation or thrill was sarcomas in adults. This tumour originates from multi present. The systemic clinical examination was within potential primitive mesenchymal cells rather than mature normal limits. Haematological and biochemical profile 1 th was normal. X-ray chest was normal. Due to the giant adipose tissue . The peak age incidence is between 4 th size and rapid growth of lesion with necrosis of overlying and 6 decade of life with slight preponderance towards skin, decision was taken to do wide surgical excision. male gender1 . They often present as relatively slow Total excision of the lesion was done witha2cmfree growing asymptomatic masses generally located in thigh, margin down to deep sub fascial plane exposing the gluteal region, retroperitoneum, leg, inguinal, gluteus maximus muscle which was found to be free of the paratesticular and shoulder area2,3 . Chest wall, breast, disease. Primary closure was done after raising adequate mediastinum, small intestine, omentum and mesentry flaps. Negative drain was kept which was removed after 2,3 may be involved . Liposarcoma can be divided according three days. Stitches were removed on 10th postoperative to clinico-pathological and cytogenetic characteristics day. Rest of the post operative period was uneventful. into three distinct subtypes : well differentiated, Surprisingly, final pathology showed yellow to white firm 4,5 myxoid/round cell and pleomorphic liposarcoma . serial section with occasional necrotic foci. Tumour was 6 Pleomorphic liposarcomas are the rarest type . We microscopically composed of spindle or oval shaped cells describe an unusual case of a rapidly growing giant arranged in haphazard manner and in wavy bundles. The gluteal pleomorphic liposarcoma which is very-very rare. cells had prominent atypia with nuclear pleomorphism CASE REPORT and hyperchormasia. There were few lipoblasts with cytoplasmic vacuoles indenting the nuclei of cells forming A 35 year old female presented to the outpatient eccentric atypical nuclei. There were presence of plenty department with 9 month history of rapidly growing mass of large bizzare giant cells with aggressive in left gluteal region. Though the mass was significantly hyperchromatic large nuclei. Extensive areas of necrosis interfering with her routine activities, walking, perineal are also seen. The microscopic histopathology revealed and perianal hygiene and even with defecation, the clear margins of the tumour in resected specimen. The patient did not seek for the treatment until that date when it final histopathological diagnosis was high grade became unavoidable because of overlying skin necrosis, pleomorphic liposarcoma. Radiotherapy was given after ulceration and foul discharge. Physical examination six weeks with a total dose of 50 Gy in 25 fractions. revealed a soft, nontender, well defined, round, mobile, Patient was followed up for about one year showing no fleshy mass of size 25x20x15 cm. Overlying skin was evidence of recurrence or metastasis. Correspondence Address : Dr. Vikas Bathla House No. - 2, A-Block, Parshwapadam Township, Near C. U. Shah Medical College and Hospital, Dudhrej Road, Surendranagar -363001. E–Mail : [email protected]

115 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 DISCUSSION FIGURE 2 – Excised specimen Pleomorphic liposarcoma is a rare neoplasm6 . Pleomorphic liposarcoma is a clinically, histologically and cytogenetically distinct form of liposarcoma and is the rarest subtype7 . It is known that this neoplasm is usually aggressive, occurring in adulthood and usually in limbs8 . Pleomorphic liposarcoma can occur in mediastinum, liver, orbit, paratesticular region and also as a pure dermal tumour8 . It usually present as a painless deep seated tumour as mass8 .Because it is so uncommon and is often difficult to differentiate from other high grade sarcoma7 . It can be easily misdiagnosed because of the great variety FIGURE 3 – At the bottom a high grade pleomorphic of histological presentations8 . Histological hallmark of cell and spindle cell proliferation is seen. pleomorphic liposarcoma are pleomorphic lipoblast which form less than 10% of the tumour8 . Immunohistochemistry has limited value in diagnostic procedure5 . Differential diagnosis includes dedifferentiated liposarcoma, myxofibrosarcoma, plemomorphic leiomyosarcoma, pleomorhphic rhabdomyosarcoma, malignant fibrous histiocytoma8 . Histologically, pleomorphic liposarcoma is characterized by a predominance of pleomorphic spindle cells with occasional multi nucleated giant cells often arranged in a storiform growth pattern with focal collection of pleomorphic lipoblasts having cytoplasmic vacuoles with eccentric nuclei with extensive area of necrosis7 . FIGURE 4 -Clusters of lipoblasts representing Pleomorphic liposarcoma is generally considered to be a lipogenic differentiation is seen at top left - Hallmark high grade sarcoma given its high rate of recurrence and of pleomorphic liposarcoma. metastasis7 . Most common site of metastasis is lungs7 . Local recurrence largely depends on the margin status at the time of surgery8 . Intralesional or marginal resection with which the margins run through the tumour or pseudocapsule has recurrence rates of 40-100%9 . Surgery with radical margins is preferred treatment options with 1-10% recurrence rates9 . In addition Mankin et al suggested radiotherapy is often helpful in decreasing the local recurrence rate post operatively10 .

FIGURE 1 – Showing mass in the left gluteal region CONCLUSION Pleomorphic liposarcoma is a rare neoplasm and to our knowledge this is the first reported case of giant pleomorphic liposarcoma of gluteal region. Complete surgical excision and adjuvant radiotherapy appears to prolong the survival and improves the quality of life in these patients with careful follow up. This case is being contributed to the literature stressing giant gluteal pleomorphic liposarcomas are very rare and a longer follow up is needed to evaluate the outcome in these cases.

116 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 REFERENCES 1. AmatoG, MartellaA, FerraraccioF, Di Martin, MaffetoneV, Fei L Del GenioA. Welldifferentiated lipoma like liposarcoma of the 7. KatherineAD, JohanRG, ElizabethAM, CyrilF. Pleomorphic sigmoid mesocolon and multiple lipomatosis of rectosigmoid liposarcoma: A clinicopathologic analysis of 19 cases.mod mesocolon: Report of a case. Hepatogastroenterology Pathol2001;14(3):179-84. 1998;45(24):2151-56. 8. LukaB, AntonijaJ, LovorkaBV, DubravkoO, Svenseiwerth. 2. MontgomeryE, Fischerc. Paratesticular liposarcoma: A Pleomorphic liposarcoma of foot; A case report. Diagnostic clinicopathologic study.Am J Surg Pathol 2003;27(1):40-47. Pathology 2008;3:15 doi:10.1186/1746_1596.3-15. 3. Dalla PalmaP, BarbazzaR. Welldifferentiated Liposarcoma of 9. Atakan Sezer, Nermintuncbilek, UfukUsta, Rusen Cosar-alas, paratesticular area: Report of a case with fine needle aspiration, irfanCicin. Pleomorphic liposarcoma of pectoralis major in an preoperative diagnosis and review of literature. Diag cytopathol elderly male: report of a case and review of literature. J Cancer 1990;6(60:421-426. Res 2009;5(4):315-17. 4. FletcherCDM. Soft tissue tumours. In Diagnostic Histopathology 10. MankinHJ, Hornicek FJ. Diagnosis, classification and of Tumours. 2nd edition. edited by FletcherCDM: Churchill management of soft tissue sarcoma. Cancer Control 2005;12:5- Livingstone; 2000:1473-1540. 21. 5. WeissSw, GoldblumJR. Liposarcoma. In Enzinger and weiss's soft tissue tumours. 4th edition edited by WeissSW, GoldblumJR, St. Louis Mo: Mosby;2001:641-693. 6. DeiTqsAP. Liposarcoma new entities and evolving concepts. Ann Diag path 2000;4:252-66.

117 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 CASE REPORT Midgut malrotation with incidental nutcracker syndrome in adulthood : case report and literature review Dr. Harish N. Raheja*, Dr. Hasmukh B. Vora**, Dr. Mahendra S. Bhavsar*** *3rd Yr Resident, **Associate Professor, ***Prof. & Head, Dept. of Surgical Gastroenterology V. S. Hospital, Smt. NHL Municipal Medical College, Ahmedabad-380006.

KEY WORDS : Malrotation of Gut, Nutcracker Syndrome.

Abstract : Malrotation of midgut is generally regarded as paediatric pathology with majority of patients presenting in childhood. The diagnosis is rare in adults which sometimes delayed in diagnosis and treatment. Initial presentation of symptomatic midgut malrotation is rare in adults. However, a significant number of cases remain quiescent during childhood. Incidental diagnosis may then occur in adulthood; when imaging investigations are carried out for other symptoms or, during surgery for unrelated pathology. It has been reported that the incidence of malrotation in adults is approximately 0.2%. Malrotation presented with nutcracker syndrome (left renal vein which was compressed between Superior mesenteric artery and aorta) is also very unusual presentation.

INTRODUCTION On examination the patient was afebrile and Mid gut malrotation is a congenital anomaly in the hemodynamically stable. The abdomen was soft, embryological development of the fetal intestine rotation. scaphoid, mild tenderness in the central, epigastric It has been estimated that it affects approximately 1 in 500 region. Routine admission, blood test including serum live births1 . However the true incidence is difficult to electrolytes, arterial blood gas analysis, liver function test, determine as a substantial number of cases are clotting profile was normal. However a full blood count demonstrated a HB level to be 13.5gm/dl with slightly undetected throughout life. 85% of cases were detected 3 2 raised total white cell count of 14.9×10 /μL and a in the first 2 years of life . Most adult diagnosed of mid gut 3 malrotation are asymptomatic patients, they are found neutrophil of 9.7 ×10 /μL. during imaging investigation for unrelated conditions or at Abdominal x-ray did not show any dilated bowel loops in operation for other pathology3 . The true diagnosis in this centre of abdomen and appear gas filled. The diagnosis age group is difficult especially because the typical remains clueless until emergency Computerized presentation is with non specific symptoms and the fact tomography (CT) scan was obtained which demonstrate that in adults, surgeons usually have low index of feature s/o malrotation (figures I&II). The patients also suspicion and may not consider the diagnosis a possibility underwent upper gastointestinal endoscopy and showed in the initial evaluation of the adult population with features of dilated first and second part of duodenum. abdominal pain. The patient was resuscitated with fluid and prepared for We are reporting a case of adult patient with acute the laprotomy. The findings at operation included dilated presentation of midgut malrotation with the dilemma of small bowel loops in the upper abdomen, on right side of preoperative diagnosis as supported by review of abdomen; caecum was at the epigastrium and left side of literature. upper abdomen (figure IV). There was fibrous band over CASE REPORT the distal part of the duodenum (figure V), on right side of duodenum confirming mid gut malrotation. Incidentally, A 28 year old female was admitted in department of intraoperatively, dilated left renal vein which was gasteroenterology with H/O of vomiting and mild pain in compressed between Superior mesenteric artery and abdomen since 7 days. She was passing flatus and aorta was noted. Retrospective examination of motions regularly. There was no associated symptoms Computerized tomography scan (figure III) confirmed the and no history of similar complaints. same.

Correspondence Address : Dr. Harish N. Raheja Room No.B-21, Doctor Quarter, V. S. Hospital, Smt. NHL Municipal Medical College, Ahmedabad-380006. E -mail : [email protected]

118 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 We offered a modified Ladd's procedure to our patient by 80%9 . Deviation from the normal positional relationship of performing a division of Ladd's bands and an superior mesenteric vein and superior mesenteric artery appendicectomy. was originally described by Nichols and Li as a useful Our patient has been completely symptom free during 12 indicator of the diagnosis of midgut malrotation. However, months of follow-up. abnormal orientation of the superior mesenteric artery- superior mesenteric vein relationship is not entirely DISCUSSION diagnostic of malrotation; it can also be seen in some Intestinal malrotation is a rare condition and the diagnosis patients without the pathology and a proportion of patients of malrotation in adults is difficult and usually not readily with malrotation may have a normal superior mesenteric considered as the cause of intra-abdominal symptoms. artery-superior mesenteric vein relationship10 . The Initial presentation of symptomatic midgut malrotation is shortened mesentery allows the small bowel and rare in adults. mesentery to twist and wrap around the narrowed Midgut malrotation is broadly considered a deviation from superior mesenteric artery pedicle to create a distinctive the normal 270 degree counter clockwise rotation of the 'whirlpool' appearance on computerized tomography gut during embryonic development during fourth week of scan. foetal development3 . It leads to various degrees of anomaly including the entire small bowel remaining on the right side of the abdomen, the caecum, appendix and colon on the left and an absent ligament of Treitz. In addition, the small bowel mesentery may develop a narrow vertical attachment and the peritoneal fibrous bands fixing the duodenum and caecum to the abdominal wall may persist. These congenital bands extend from the right lateral abdominal wall, across the duodenum and attach to the undescended caecum and are known as Ladd's bands4,5,6,7,8 . Ladd's bands compress the Computerized tomography (CT) scan image shows duodenum and can potentially cause duodenal abnormal position of duodenal jejunal flexure on right side. obstruction. Two distinct patterns of adult presentations have been reported in the literature4,5 : acute and chronic. Chronic presentation is more common in adults. The symptoms may be highly nonspecific. However, the range of clinical presentations, underlines the need for a high index of suspicion of midgut malrotation, when investigating the cause of intermittent and varying abdominal symptomatology in a healthy young adult. Moldrem et al9 reported that 48.5% of their thirty-three patients presented with an acute abdomen. Acute presentation may be due to volvulus of the midgut or ileocaecum, reported as the most common cause of Computerized tomography (CT) scan showing inverse bowel obstruction in adults with gut malrotation. relationship of SMA to SMV and jejunal loops on right side. We can expect an increase in the incidental diagnosis of gut malrotation with increasing and widespread use of radiological investigations. Diagnostic features of midgut malrotation can be identified using plain abdominal radiograph, ultrasound scan (USS), computerized tomography (CT) scan, magnetic resonance imaging (MRI) scan and mesenteric arteriography9,10 . Abdominal colour doppler USS may reveal malposition of the superior mesenteric artery, raising the suspicion of gut malrotation with or without the abnormal location of the hollow viscus9,10 . Computerized tomography scan is now considered the Computerized tomography(CT) scan image shows investigation of choice; providing diagnostic accuracy of compression of left renal vein between aorta and SMA.

119 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 REFERENCES 1. TorresAM, Ziegler MM. Malrotation of the intestine. World j Surg 1993; 17:326-331. 2. Mclntosh R, Donovan EJ. Disturbances of rotation of the intestinal tract. Am j Dis child 1939; 56:116-166. 3. Dietz DW, Walsh RM, Grundfest-Broniatowski S, Lavery IC, Fazio VW, Vogt DP: Intestinal malrotation : a rare but important cause of bowel obstruction in adults. Dis Colon Rectum 2002, 45(10):1381-1386. 4. Ladd WE: Surgical disease of the alimentary tract in infants. Engl J Med 1936, 215:705-708. Per op image shows high caecum and appendix 5. Fu T, Tong WD, He YJ, Wen YY, Luo DL, Liu BH: Surgical located on left side of the abdomen management of intestinal malrotation in adults. World Journal of surgery 2007, 31:1797-1803. 6. Wang CA, Welch CE: Anomalies of intestinal rotation in adolescents and adults. Surgery 1963 Dec; 54:839-855. 7. Matzke GM, Moir CR, Dozois EJ. Laparoscopic Ladd procedure for adult malrotation of the midgut with cocoon deformity: report of a case. J LaparoendoscAdv Surg TechA2003, 13:327-329. 8. Matkze GM, Dozois EJ, Larson DW, Moir CR: Surgical management of intestinal malrotation in adults: comparative results for open and laparoscopic Ladd procedures. Endosc 2005, 19:1416-1419. 9. Moldrem AW, Papaconstantinou H, Broker H, Megison S, Per op image shows Ladd's band encircling duodenum. Jeyarajah DR: Late presentation of intestinal malrotation : an argument for elective repair. World J Surg 2008, 32:1426-1431. 10. Pickhardt PJ, Bhalla S: Intestinal malrotation in adolescents and adults: spectrum of clinical and imaging features. American Journal of Radiology 2002, 179:1429-1435.

120 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 CASE REPORT A Case Series of Gestational Trophoblastic Tumor - Benign Mole To Life Threatening Perforating Mole.

C. S. Vyas*, M. P. Patel*, Amar Mukhi**, S. B. Vaishnav*** *Associate Professor, **2nd Year Resident, ***Professor, Department of Obs & Gynec, P.S.Medical College, Karamsad. KEY WORDS : Gestational trophoblastic neoplasia, Invasive Mole

ABSTRACT Gestational trophoblastic neoplasms (GTN) are proliferative as well as degenerative disorders of placental elements. Over the last four decades, GTN has developed from one of the most fatal malignancies to one of the most curable disease.Asimple serum HCG may be all that is needed to clinch the diagnosis. It is important that the condition be diagnosed early for intervention and chemotherapy, which is curative in almost all cases.

Eـ&ided SـG guـUS ـnder GAـven. Uـre giـPCV weـ ٥ INTRODUCTION w Total isـnsent. Hـwritten coـ & formedـtaining inـGestational trophoblastic neoplasms (GTN) are otas done after ob daـــmplete hyـــco ـــatures ofـــe feـــowed thـــproliferative as well as degenerative disorders of tpathology sh emــent chـngle agـth siـeated wiـs trـhe waـle. Sـplacental elements and include complete or partial oidiform mo dyــmg/kg boــthotrexate (۱ــMe ــcourses of ٥ ,e ــ,hydatidiform mole (90%), invasive mole (5-8%) which therapy i Eــ&ter SــG afـta hCـerum Beـid. Sـllinic acـnd foـight) aـwwe could also be metastatic, villous or avillous emــــــch ـــــmpletion ofـــــter coـــــand afـــــ ۹٦٠IU/Lـــــoas ۱٢ choriocarcinoma (1-2%), and placental site tumor (1- sــPatient wa ــ.٣٣IU/Lــ٣۹ sـG waـta hCـrum Beـdtherapy se 2%).1 . Over the last four decades, GTN has developed ischarged on ۱٠thday of evacuation.Mole. from one of the most fatal malignancies to one of the most Invasive Mole ----٢ curable, with the advent of a very sensitive tumor marker Case ssـal claـer socio-economicـyear old female from low ٢٥ HCG), identification of prognostic factors, development ,A) ntــgy outpatieــhe gynecoloــto tــ ۱۱ــ٢٠.٢٣.٠۹ onـ edـof effective chemotherapy and finally the judicious use of report ngـof bleediـ surgery and radiotherapy for selected patients. Here we department of PSMC, with the chief complain ry, D&Eـng histoـOn evaluatiـ .ysـda ۱٠ـ stـor laـreport such three rare cases of 1: Complete mole, 2: per vagina f alـte hospitـat a privaـ onـof gestatiـ weeks Invasive mole, 3: perforating invasive mole with their ,was done for ۱٠ ofـــ tsــme producــat tiــat thــ & ckــhs baــlf montــne & haــsuccessful management. o erـno furthـ ,leـconception were suggestive of vesicular mo Case 1—Complete Mole veــli ٢ thــda wiــTH graviــ٤ asــhe wـle. Sـas availabـrt wـrepo onـal conditiـus & generـA, 40 year old female, G9P8A0L8 at 4 months of issues. On admission her vital stat ssـamenorrhoea was admitted on 11.10.2011 in the .was stable. On abdominal palpitation there was no ma ntــas preseــng wــon spottiــum examinatiـer speculـOn pـ. ,emergency ward of Obst & Gynec department, PSMC eeـth frـus wiـky uterـed a bulـKaramsad with the chief complain of bleeding per vagina Bimanual examination reveal IU/Lـ ٠٠ـ٢۱٦) edـas raisـCG wـta hـfor last 1 month, moderate in amount and associated with .)fornices. Her serum Be erـle. Hـve moـof Invasiـ veـas suggestiـclots. There was no other positive history. T: normal PR: Ultrasonography w reـgs weـAs findinـ .alـre normـFT weـFT & Rـbd chest X-ray, Lــr Aـin. On Peـm/٠ـ٣ :mmHg, RRـ ۹٠/٠ـin BP: ۱۷ـm/٢٦ـmo۱ asـــly wـــer famiـــas hـــ & leـــve moــof invasiــ veــNoren ute suggestiـ .lـfee ـdoughy ـ,relaxedـ ,zeـ٣٠wks si-٢٨ us was veـــــgo operatiــــto underــــ edــــhe decidــــed, sــــw complet ـal osـervicـafetal parts felt, FHS not found. Per Vagina: C neــas doــmy wـal hysterectoـal abdominـon. Totـre interventiـke structuـpe liـgra ـandـ s presentـding waـblee ـ,open ـss ofـــ ceـــed presenـــgy confirmـــSA. Histopatholoـــ erـــcu undـVesiـ was ofـ osisـional diagnـrovisـal were coming out. P ntـــle ageـــth singـــed wiــas treatــhe wــle. Sــve moــC: invasiـــــm%, Tــــ٢.٣g e: Hbــــwerــــ onsــــnvestigatiــــr Mole. I ٣ idـic acـnd follinـ٢doses of Methotrexate a ,m .chemotherapy ـــcumm, with/٠ـــ٣٣٦٠٠ــ :ountــet Cــlatelــcumm, P/li٦٠٠٠ ofـ ysـda ۱٠ـ m On follow up her repeat serum Beta hCG afterــــineseruــــBasel .ــــrofileــــcoagulation pـــ teredـــBdly al Co .surgery was ۱٨٣IU/Lــ of ــtiveـuggesـwas s ـ٠IU/L. USGـ٦٥٤٠٠ asـmeta hCG w ,plete VesicularOn examinationshe was severely pale Correspondence Address : Dr. Chetna S Vyas Department of Obstetrics and Gynecology, Pramukhswami Medical College, Shree Krishna Hospital, Karamsad-388325. Dist. Anand, Gujarat

121 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 Perforating Invasive Mole Perforating Mole ---٣ Case ssـic claـer socioeconomـom lowـle frـld femaـrs oـyea ٢٥ـ A ckـin shoـ ۱٠ـ۱٠.٢٠.٢٨ onـ ,adـpresented at PSMC, Karams st ۱ــor laــna fــer vagiــng pــof bleediــ inـef complaـth chiـwi or ۱ـng fـle feeliـys & uncomfortabـda ٢ month, fever for last onـ & ffـhour. Patient had complained of vaginal bleeding o heـra. Sـof amenorrhoـ hsـmont ٢ for last ۱ month following ssـed weakneـnd generalizـin aـst paـwas also having che. of ۱ــ ryــth histoــas G٤P٢A۱L۱ wiــry wــic histoـer obstetrـH alـــnd generـــus aــal statــer vitــon hــOn admissiــ .CSــLS orـof pallـ eeـre degrـng seveـor; showiـre poـon weـconditi, s/mـــــ٣٢breath , orـــــon monitـــــ inـــــm/ia() ۱۷٢ـــــtachycard pi ــــinalــــe. On abdomـــdablـــot recorـــwas nـــ an) and B.P exـــ lumــpecuــOn per sــ .ntــwas preseــ guarding ــalpation uaـOn bimanـ .ntـwas preseـ lmination excessive bleeding ceــــ ,ntــــg was preseـــballooninـــ on cervicalـــexaminatiـــr ag DISCUSSIONـn felt in vـtioـof concep ـproductsـ ,edـilatـ٢cm d asـivix w byـــ lyـــed histologicalـــis characterizـــ cyــar pregnanــst Molـs suggeـch waـwhi ـ,oneـSG was dـina. Urgent bedside U ngـــof varyiــ ngــli consistiــic vilــof chorionــ esــl abnormalitiــــicaــــCerv ـــ? Mole or ـــl Vesicularـــicaـــe of ? CervـــerPv ofــ maــnd edeــon aــic proliferatiــof trophoblastــ esــdegre ٥-ــــtion showed Hbــــinvestigaــــ lineـــHer base .ـــgnancy. toـ ilـes faـar pregnanciـse molـof theـ villous stroma. Some ٤۱ـ,count- ۱ـ teletـl plaـm, and totaـcum/٠٠ـ٨۱ -۱gm%, TLC, TNـin Gـ ltـnd resuـnt aـry treatmeـng primaـss followiـLF regreـ .alteredـ tlyـas slighـion profile wـcumm. Coagulat/ـT٠٠٠ ntـma, persisteـal which can be invasive mole, choriocarcinoــe normــhest werــtes & X-ray cـectrolyـum Elـser ,ـRFT ,. icـــte trophoblastــal siــnd placentــor aــic tumــti trophoblastـresuscitaـ erـl. Aftـ/IU ٥۹۷٣- o Serum Beta hCG was raised ٢ or .tumorـــconsent fــ informedــithــD&E w ــfor ــakenــn she was t msـng symptoـth followiـnt wiـro :Invasive mole usually preseــlood pــblood & bـ adequateـ omy, keepingـrectـcudhyste neــst, uteriــne cyــca luteiــng, theـal bleediـar vaginـe irregulــestivــwere sugg ــductsــdone; proــ E wasـ&ready. Dـ ots ndــــnt aــــal enlargemeــــor asymmetricــــ onــــft subinvolutiـــe started aـــal hemorrhagــrentiــMole. Tor ــlarــef Vesicu veـt can deـE .IـS/ ls٢ـop lpersistently elevated serum hCG leveــ On ــ.was done ــlaprotomy ــforeـand there ـettingـer cur heـــT . Eor٣&ـــntby Dـــtmeـــafter treaـــ & eforeــboth b ــe opــــitoneal hemorrhagــــintraperــــ ,enـــhe abdomـــng tـــwni neـــــhe uteriـــــte tــــay perforaــــor mــــic tumــــgi trophoblastـingat the reـforatـmole, perـiveـoas present. It was invas ndــng aــal bleediــin intraperitoneــ ngـum resultiـn of isthamustachypnoea (()( left uterine vessels as shown myometri orـــ leـــde singــay incluــnt mــng. Treatmeــal bleediــavi vaginـlife s ـneas aـdo ـy wasـtotal hysterectom; in figure ۱) n٦ ndـle aـte combined chemotherapy according to patient profiـected uـf the bisـce oـranـgross appeaـ rng measure. The usـ toـ edـad reportـty risk status. Our case of invasive mole hـaviـtrial cـus showed a necrotic mass inside the endome edـo with complaint of persistent vaginal bleeding and showــng tــatiــh was penetrــwhicــ hamusــel of istــlevــ t theــta seـer caـer D&E. OthـCG aftـta hـes constant rise of serum Beـــــــn was prــــــatioــــــm and perforــــــtriuــــــnehe myome alـــth intraperitoneـــed wiـــle presentـــng moـــof perforatiــ irـــcimen confـــctomy speـــgy of hystereـــoloـــmt. Histopath gyـts histopatholoـhemorrhage & shock. In both the patien ivــPost operat ــ.mole ــiformــvical hydatidـasive cerـeed Inv ofـ ntـof treatmeـ ceـle. Choiـve moـed invasiـreport confirm otـ with ـpportـlator suـhly patient was shifted to ICU on venti byــ edــon, followــon evacuatiــis suctiــ cyــar pregnanــmol ctــــــbroad speـــــ with ـــــ,ementـــــrtive managـــــrer suppo beــــ anــــri cــــge uteـــng larـــge. Evacuatiـــrp curettaـــsha atـpost oper ـth ۱٤ـDS oـAR ـlopedـium antibiotics. She deve toـ ueـbe dـ toـ complicated by the onset of ARDS, believed d ـal ۱٢ـtotـ r forـlatoـCU on ventiـyave day. She was kept in I ofـ seـur caـon. Oـhe circulatiـto tـue inـar tissـrelease of mol Inـ .lyـst operativeـDS poـed ARـle developـng moـperforati ۹ـ totalـ eivedـd she recـerioـative pـCPs. In intra & post oper ٨ inـve withـme negatiـls becoـti,V most patients, the HCG leveــــually paــــFFP. Grad ٤ــــ & trateــــtelet concenــــpla ٤ e thــ esـhe valuـIf tـ .leـhe moـof tـ onـer evacuatiـks aftـwee ۱٢ـ st toــrd on poــwa ــed toــiftــe was shــd shــd anــroveـnt imp ٣ anــre thــor moــau fــor plateــ ghــly hiــin persistentــks remaـwee ٤ erـoperative day. Her repeat serum Beta hCG aft ntـve malignaـto haـ edـis considerـ IU/L weeks, then the patient ٦ weeks it was ٦ IU/L and after was ۱۷٦.

122 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 CONCLUSION REFERENCE //:al 1. Miller FH, Laing FC. Gestational trophoblastic disease httpـar clinicـnd similـes aـhe casـof tـ tyـhe rariـng tـConsideri full.html. ۱۹۹٤/٣٤/le brighamrad. harvard. edu/ cases/bwh/hcacheــue. A simpـre uniqـts aـse reporـse caـon, theـpresentati .seـic Diseaـhe 2. Berkowitz R S, Goldstein D P. Gestational Trophoblastــch tــto clinــ edــis needــ atـll thـbe aـ ayـCG mـum Hـser edــ thــgy, ۱٤ــak's Gynecoloـek & Novـrt R D. Berـek J S, ReinhaـBer, ٢٠٠۷: p۱٥٨۱-۱٦٠٤ ,ed .Philadelphia, Lippincott Williams & Wilkinsـbe diagnosـ diagnosis. It is important that the condition .Danielsson K.About. Com: ۱-٤ .٠٨.٣٠.٠۱ is 3. Invasive Mole.Updatedـــ chـــpy, whiـــnd chemotheraــon aــor interventiــly fــear alــt gestationــistenــpers ــiskــLow rــ .L et al ــnd S, Holdenـcklaـis 4. Striـ curative in almost all cases. Single drug chemotherapy doـ with low ـreatmentـtial tـTN strophoblastic disease: outcome after iniـــof Gــ ntــal managemeــhe optimــT . nt٤ــen sufficieــoft :٢ـ٢٠٠ ncolـJ Clin O .٢٠٠٠-he e methotrexate and folinic acid from ۱۹۹٢ـdepends on prompt diagnosis, correct stratification of t McNeish IA.٤٤-us ,۱٨٣٨ــng varioـnt usiـte treatmeـnd appropriaـry aـsk categoـri Itـــ .ryـــnd surgeـــpy aـــas chemotheraــ chــes suــmodaliti onـan uncommـ isـ itـ Asـ .requires multimodality approach inـ disease, it is best that all patients be referred to experts isـis thـ Itـ .ntـir managemeـth theـar wiـreferral centre famili alـly fatـst uniformـan almoـ edـas convertـat hـse thـexperti .disease into a very curable one

123 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 CASE REPORT Congenital Intra-hepatic Porto-systemic Venous Shunt in an adult male. Dr. Megha Sanghvi*, Dr. Yashpal Rana**, Dr. Hemant Patel*** *M.D., Assistant Professor, Radiology, B.J.Medical College, Civil Hospital, Ahmedabad, Gujarat) **M.D., Consultant Radiologist, U.N.Mehta Institute, Ahmedabad, Gujarat) ***M.D., D.M.R.E, Samved Hospital, Gujarat Imaging Centre, Ahmedabad, Gujarat) KEY WORDS : Porto-systemic shunt, adult, congenital.

ABSTRACT : Intrahepatic porto-systemic venous shunt is rare [1–3 ]. Early diagnosis is important as the condition can lead to hepatic encephalopathy [2 ]. To our knowledge, very few cases of congenital intrahepatic porto-systemic venous shunt have been reported. We report one such case of a patient, who presented with history of occasional loss of consciousness and was diagnosed with a congenital porto-systemic venous shunt [1 ].

CASE REPORT was preserved. These findings suggest type-IIb porto- A 40-year-old male weighing 60 kg was referred to our caval fistula. The portal vein at porta was 15 mm in hospital for CT scan of abdomen and pelvis for evaluation diameter and splenic vein at splenic hilum - 9 mm. of episodes of loss of consciousness. The patient was Screening MRI of liver confirmed the above findings of CT. otherwise normal. The patient had no complaints of In addition, it revealed presence of multiple discrete abdominal pain, fever or convulsions. There was no altered signal intensity lesions in both lobes of liver. The history of liver surgery or biopsy. lesions appeared hypointense on T2W images, suggest At physical examination, no evidence of hepato- regenerative nodules. splenomegaly or congestive hepatic failure was found. DISCUSSION Laboratory studies showed a total bilirubin level of 0.8 Porto-systemic venous shunts within the hepatic mg/dL, conjugated bilirubin level of 0.4 mg/dL, serum parenchyma are extremely rare and are caused by either alkaline phosphatase level of 40 U/L, serum aspartate a congenital vascular malformation or a collateral transaminase level of 30 U/L, and serum alanine pathway secondary to cirrhosis of the liver and portal transaminase level of 30 U/L. hypertension or post-traumatic variety [3 ]. The findings on echocardiography were normal. EMBRYOLOGY Abdominal sonography showed mild hepatomegaly with Congenital anomalies of the portal venous system result the liver exhibiting an altered echotexture. A well defined from abnormal coalescence of the vitello–umbilical cystic lesion was seen in the right lobe of liver which venous plexus during embryogenesis. They may be showed communication with the intrahepatic INFERIOR associated with congenital cardiac defects or VENACAVA on colour doppler study. However, the right abnormalities of the hepato-biliary system, like abnormal and left portal veins, right, middle and left hepatic veins lobulation of the liver, hepatoblastoma, and extrahepatic showed normal caliber and normal phasic flow. biliary atresia. Multislice 64 Slice CT imaging with reformatted images CLASSIFICATION was performed using sub millimeter thin contiguous axial scan of abdomen and pelvis with I.V. contrast. The study Morgan and Superina [2] introduced a classification revealed evidence of mild hypertrophy of caudate lobe system for extrahepatic portosystemic shunts. with heterogeneous liver parenchyma. A few hypodense Type I Abernethy malformation - Congenital absence of minimally enhancing lesions were seen involving both the portal vein occurs frequently in girls and is associated lobes of liver. Collaterals were seen at porta, peri- with other anomalies [3,4]. Liver transplantation, which pancreatic and peri-splenic regions. Communication was offers the only option for cure, is reserved for patients with seen between intrahepatic segment of main portal vein & refractory symptoms despite medical management. inferior venacava. However, the intrahepatic portal flow Type II PSS have more variability for anatomy, clinical

Correspondence Address : Dr. Megha Sanghvi M.D., Assistant Professor, Radiology, B.J.Medical College, Civil Hospital, Ahmedabad, Gujarat)

GMJ 124 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 features, and treatment options. Hyperammonemia, DIAGNOSIS which is due to shunting of blood away from the portal Color Doppler combined with pulsed Doppler sonography circulation, has been a commonly reported problem [5,6] is a highly efficient noninvasive procedure for diagnosis of as was seen in this patient. Subtle symptoms of intrahepatic porto-systemic venous shunts that obviates encephalopathy manifest in adulthood [5,7]. angiography[2]. Regenerative liver lesions and pulmonary hypertension have been also been associated [3,4,7]. A diagnosis of congenital intrahepatic porto-systemic venous shunt was made on color Doppler sonography Intrahepatic porto-systemic shunts are classified into four and Contrast enhanced CT scan in the present case. morphological types. However, the early changes of cirrhosis in the liver with Type I – most common type, a single large vessel of the development of regenerative nodules were visualized constant diameter connecting the right portal vein to only on MR imaging. inferior venacava. The choice of treatment of intrahepatic porto-systemic Type II – localized peripheral shunt in which single or venous shunts is controversial. The vascular anomaly multiple communications are found between peripheral may regress spontaneously during infancy. Patients with branches of portal and hepatic veins in one hepatic type II congenital PSS are benefited by occluding the segment. abnormal communication by surgical banding or coil Type III – an aneurysmal communication between the embolization using stainless steel or platinum coils. peripheral portal and hepatic veins. Successful shunt closure can alleviate symptoms of hyperammonemia and neurologic symptoms, result in Type IV – multiple communications between portal and resolution of regenerative liver nodules, reverse growth hepatic veins distributed in both lobes of liver. impairment, and improve coagulopathy. However, semi- Table 1 - Classification of congenital extra-hepatic PSS I No intrahepatic portal flow (CAPV or type I Abernethy malformation) II Partial shunt with preserved hepatic portal flow (type II Abernethy malformation) IIa Arising from left or right portal vein (includes PDV) IIb Arising from main portal vein (including its bifurcation or splenomesenteric confluence) IIc Arising from the mesenteric, gastric, or splenic veins CAPV indicates congenital absence of the portal vein. CAPV- CONGENITAL ABSENCE OF PORTAL VEIN Table 2 - Classification of congenital intra-hepatic PSS I A single large vessel of constant diameter connecting the right portal vein to inferior venacava II Localized peripheral shunt in which single or multiple communications are found between peripheral branches of portal and hepatic veins in one hepatic segment III Aneurysmal communication between the peripheral portal & hepatic veins IV Multiple communications between portal and hepatic veins distributed in both lobes of liver FIGURES LEGENDS FIGURE 1 FIGURE 2 Axial Contrast enhanced CT scan images reveal dilated T1W MRI AXIAL images show presence of right and left main portal vein with communication between the main portal veins, dilated main portal vein showing portal vein and IVC. communication with the intrahepatic IVC.

125 I.M.A.G.S.B. NEWS BULLETIN / DECEMBER - 2013 Vol. 8 No. 12 FIGURE 3: FIGURE 4 : T2W AXIAL MRI images reveal well defined hypointense Volume rendered images in coronal plane reveal the lesions in the right lobe of liver that suggest regenerative fistula between the main portal vein and intrahepatic IVC. nodules.

closure of the shunt is performed because completely REFERENCES suturing the shunt might result in life-threatening 1. Abernethy J. Account of two instances of uncommon formation in complications related to severe portal hypertension if the the viscera of the human body. Phil Trans R Soc 1793;83:59-66. intrahepatic portal venous system could not 2. Morgan G, Superina R. Congenital absence of the portal vein: two accommodate the sudden restoration of normal blood cases and a proposed classification system for portasystemic flow. vascular anomalies. J Pediatr Surg 1994;29:1239-41. 3. Howard ER, Davenport M. Congenital extrahepatic portocaval CONCLUSION shunts—the Abernethy malformation. J Pediatr Surg Type II congenital intrahepatic porto-systemic shunt is a 1997;32:494-7. rare condition which may be asymptomatic until 4. Stringer MD. The clinical anatomy of congenital portosystemic venous shunts. ClinAnat 2008;21:147-57. adulthood. However, early diagnosis by imaging is necessary to prevent misdiagnosis as psychiatric or 5. Akahoshi T, Nishizaki T, Wakasugi K, et al. Portal-systemic encephalopathy due to a congenital extrahepatic portosystemic neurologic disorder and for early treatment which can shunt: Hepatogastroenterology 2000;47:1113-6. prevent changes of cirrhosis and appearance of 6. Ikeda S, Sera Y, Ohshiro H, et al. Surgical indications for patients symptoms of hepatic encephalopathy in the patient. with hyperammonemia. J Pediatr Surg 1999;34:1012-5. 7. Witters P, Maleux G, George C, et al. Congenital veno-venous malformations of the liver: widely variable clinical presentations.J Gastroenterol Hepatol 2008;23:e390-4.

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